Provider Demographics
NPI:1174618623
Name:CLARK, JOHN LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LOUIS
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1VETERANS DRIVE, SURGICAL SERVICE/112
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417
Mailing Address - Country:US
Mailing Address - Phone:612-725-2065
Mailing Address - Fax:612-725-2227
Practice Address - Street 1:1VETERANS DRIVE, SURGICAL SERVICE/112
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417
Practice Address - Country:US
Practice Address - Phone:612-725-2065
Practice Address - Fax:612-725-2227
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN356192086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology