Provider Demographics
NPI:1215132410
Name:CLARK, JUSTIN JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:JAMES
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 1:5757 GREECE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99516-6216
Mailing Address - Country:US
Mailing Address - Phone:808-387-4441
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3702
Practice Address - Country:US
Practice Address - Phone:907-580-1243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7555208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery