Provider Demographics
NPI:1154338945
Name:CLARK, PAUL K (DC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:K
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 1:725 E COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-2303
Mailing Address - Country:US
Mailing Address - Phone:219-696-1910
Mailing Address - Fax:815-839-9001
Practice Address - Street 1:725 E COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:IN
Practice Address - Zip Code:46356-2303
Practice Address - Country:US
Practice Address - Phone:219-696-1910
Practice Address - Fax:815-839-9001
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001448A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000314573OtherANTHEM BCBS PROVIDER NO
IN200010730Medicaid
IN000000314573OtherANTHEM BCBS PROVIDER NO
INU45557Medicare UPIN