Provider Demographics
NPI:1528147543
Name:STEVENS, CLARK WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:WILLIAM
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:704 S WEBSTER AVE
Mailing Address - Street 2:OBGYN ASSOCIATES OF GREEN BAY LTD
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-468-3443
Mailing Address - Fax:920-432-6313
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:OBGYN ASSOCIATES OF GREEN BAY LTD
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-468-3443
Practice Address - Fax:920-432-6313
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI39553207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32400300Medicaid
WI32400300Medicaid