Provider Demographics
NPI:1528622123
Name:CLARK, REECE EVAN
Entity type:Individual
Prefix:
First Name:REECE
Middle Name:EVAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E 22ND ST STE A
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6102
Mailing Address - Country:US
Mailing Address - Phone:630-932-2055
Mailing Address - Fax:630-932-2059
Practice Address - Street 1:500 E 22ND ST STE A
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6102
Practice Address - Country:US
Practice Address - Phone:630-932-2055
Practice Address - Fax:630-932-2059
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036165661207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology