Provider Demographics
NPI:1891874665
Name:CLARK, MARK P (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3746 FOOTHILL BLVD # B140
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1740
Mailing Address - Country:US
Mailing Address - Phone:310-445-5999
Mailing Address - Fax:323-544-4248
Practice Address - Street 1:3746 FOOTHILL BLVD # B140
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91214-1740
Practice Address - Country:US
Practice Address - Phone:310-445-5999
Practice Address - Fax:323-544-4248
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50527208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G505270Medicaid
A51712Medicare UPIN
00G505270Medicare ID - Type Unspecified