Provider Demographics
NPI:1396733093
Name:CLARK, DANIEL C (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:C
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 1:640 KOLTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3570
Mailing Address - Country:US
Mailing Address - Phone:724-357-7196
Mailing Address - Fax:724-357-7279
Practice Address - Street 1:841 HOSPITAL RD STE 2300
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3699
Practice Address - Country:US
Practice Address - Phone:724-357-7196
Practice Address - Fax:724-357-7279
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046505L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018210180003Medicaid
PA0018210180003Medicaid
PAF94767Medicare UPIN
PAF94767Medicare UPIN
PA114180OtherUMWA
PW1512145OtherGATEWAY
PA113884OtherMEDPLUS
PA5945526OtherAETNA - NON HMO
PA213453OtherUPMC
PA2515712OtherAETNA HMO
PA0018210180003Medicaid