Basic Information
| Provider Information | |||||||||
| NPI: | 1346206430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286585 | ||||||||
| FaxNumber: | 6053286512 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 E 8TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINNER | ||||||||
| State: | SD | ||||||||
| PostalCode: | 575802634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058422626 | ||||||||
| FaxNumber: | 6058423557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 03/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5797 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 1151 | SD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 711298000 | 05 | MN | MEDICAID | 14513 | 05 | ND | MEDICAID |