Provider Demographics
NPI:1396799342
Name:CLARK, DANIEL COLE (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:COLE
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 1:500 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5302
Mailing Address - Country:US
Mailing Address - Phone:501-664-3914
Mailing Address - Fax:501-664-5246
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5302
Practice Address - Country:US
Practice Address - Phone:501-664-3914
Practice Address - Fax:501-664-5246
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-63092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133843609Medicaid
TX167938304Medicaid
TX167938302Medicaid
AR182459001Medicaid
TX167938301Medicaid
TX167938303Medicaid
TX8C2508Medicare PIN
TX8B8958Medicare PIN
TXP00108488Medicare PIN
TX167938302Medicaid
TX133843609Medicaid
H69828Medicare UPIN
TX167938303Medicaid