Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086X0206X | Surgical Oncologist | 35619 | MN |
NPI | 1174618623 |
---|---|
Provider Name | Dr. John Louis Clark |
First Address | Minneapolis, MN 55417 |
Second Address | Minneapolis, MN 55417 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2006 |
Last Update Date | 08/07/2007 |