Provider Demographics
NPI:1568432557
Name:CLARK, RICHARD TRAVIS (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:TRAVIS
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 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-1476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD602120112085R0202X
NMMD2018-01422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2017034Medicaid
WA0365599OtherL&I SWEDISH RADIA EDMONDS
WA1568432557Medicaid
WA0293210OtherL&I
WA0365598OtherL&I RADIA-KING COUNTY
WA0365600OtherL&I EVERGREEN RADIA
WA158600OtherPTAN
WA0365595OtherL&I RADIA-REST OF WA
WAP01775446Medicare PIN
WA0365599OtherL&I SWEDISH RADIA EDMONDS
WAG8961382Medicare PIN
WAG8961383Medicare PIN
WA0365598OtherL&I RADIA-KING COUNTY
WA1568432557Medicaid
WAG8961380Medicare PIN