Provider Demographics
NPI:1336159482
Name:CLARK, JAMES E (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:E
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 1:3021 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2369
Mailing Address - Country:US
Mailing Address - Phone:360-825-6511
Mailing Address - Fax:360-825-6536
Practice Address - Street 1:3021 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2369
Practice Address - Country:US
Practice Address - Phone:360-825-6511
Practice Address - Fax:360-825-6536
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1062207Medicaid
WA8928598OtherSTATE CRIME VICTIMS
WA126689OtherSTATE L&I
WAGAB07306Medicare PIN
WA8928598OtherSTATE CRIME VICTIMS