Provider Demographics
NPI:1124120639
Name:CLARK, MARK W (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6216
Mailing Address - Country:US
Mailing Address - Phone:740-360-7300
Mailing Address - Fax:440-282-1192
Practice Address - Street 1:1147 MEISTER RD
Practice Address - Street 2:SUITE 15A
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-5111
Practice Address - Country:US
Practice Address - Phone:440-282-1147
Practice Address - Fax:440-282-1192
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2961111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor