Provider Demographics
NPI:1063574788
Name:CLARK, GUY (MD)
Entity type:Individual
Prefix:
First Name:GUY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 CASTILLO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-4301
Mailing Address - Country:US
Mailing Address - Phone:805-682-7570
Mailing Address - Fax:805-687-3776
Practice Address - Street 1:2419 CASTILLO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4301
Practice Address - Country:US
Practice Address - Phone:805-682-7570
Practice Address - Fax:805-687-3776
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG1009A207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G10090Medicaid
CAA37815Medicare UPIN
CAW1767Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER