Provider Demographics
NPI:1447288311
Name:CLARK, KIRBY DWIGHT (MD)
Entity type:Individual
Prefix:DR
First Name:KIRBY
Middle Name:DWIGHT
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:UFP PHALEN VILLAGE CLINIC
Mailing Address - Street 2:1414 MARYLAND AVENUE EAST
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106
Mailing Address - Country:US
Mailing Address - Phone:651-772-3461
Mailing Address - Fax:651-772-2605
Practice Address - Street 1:UFP PHALEN VILLAGE CLINIC
Practice Address - Street 2:1414 MARYLAND AVENUE EAST
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106
Practice Address - Country:US
Practice Address - Phone:651-772-3461
Practice Address - Fax:651-772-2605
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN45690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA024OtherCHAMPUS
MNHP54853OtherHEALTHPARTNERS
MN01-21349OtherMEDICA CHOICE & PRIMARY
IA0567727Medicaid
MN128460600Medicaid
MN2374581OtherARAZ
MN676T8CLOtherBCBS
MN1044612OtherPREFERRED ONE
MN135432OtherUCARE
MN135432OtherUCARE
MN1044612OtherPREFERRED ONE
MNH92410Medicare UPIN
MNA024OtherCHAMPUS