Provider Demographics
NPI:1063677524
Name:CLARK, GARRETT (DO)
Entity type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:5401 PEACH ST
Practice Address - Street 2:SUITE 3500
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2601
Practice Address - Country:US
Practice Address - Phone:814-868-2179
Practice Address - Fax:814-868-2346
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022612880004Medicaid
PA1022612880004Medicaid