Basic Information
Provider Information | |||||||||
NPI: | 1568432557 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARK | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | TRAVIS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19020 33RD AVE W | ||||||||
Address2: | SUITE 210 | ||||||||
City: | LYNNWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 980364748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4255631500 | ||||||||
FaxNumber: | 4255631374 | ||||||||
Practice Location | |||||||||
Address1: | 2211 LOMAS BLVD NE | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871062719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052721476 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2006 | ||||||||
LastUpdateDate: | 03/28/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD2018-0142 | NM | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60212011 | WA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 0365600 | 01 | WA | L&I EVERGREEN RADIA | OTHER | 158600 | 01 | WA | PTAN | OTHER | 1568432557 | 05 | WA |   | MEDICAID | 0365595 | 01 | WA | L&I RADIA-REST OF WA | OTHER | 0293210 | 01 | WA | L&I | OTHER | 0365599 | 01 | WA | L&I SWEDISH RADIA EDMONDS | OTHER | 0365598 | 01 | WA | L&I RADIA-KING COUNTY | OTHER | 2017034 | 05 | WA |   | MEDICAID |