Provider Demographics
NPI:1386730836
Name:CLARK, GREGORY JAMES (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
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:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-8100
Mailing Address - Fax:515-643-8139
Practice Address - Street 1:800 E 1ST ST STE 1700
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-2100
Practice Address - Country:US
Practice Address - Phone:515-643-8100
Practice Address - Fax:515-643-8139
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-43163207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1942185Medicaid
MN101225800Medicaid
MN8T180CLOtherBCBS MPIN
MN110164901OtherRR MEDICARE
MN115522OtherUCARE
MN115522OtherUCARE
IA1942185Medicaid