Provider Demographics
NPI:1487602405
Name:SODERLUND, CLARK TORSTEN (MD)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:TORSTEN
Last Name:SODERLUND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:568 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-3408
Mailing Address - Country:US
Mailing Address - Phone:310-214-0811
Mailing Address - Fax:310-793-4634
Practice Address - Street 1:3565 DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1637
Practice Address - Country:US
Practice Address - Phone:319-214-0811
Practice Address - Fax:310-793-4634
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61166207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG75689Medicare UPIN