Provider Demographics
NPI:1568456036
Name:CLARK, RANDOLPH A (MD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:A
Last Name:CLARK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 W DUNLAP AVE STE 290
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-2759
Mailing Address - Country:US
Mailing Address - Phone:602-789-0344
Mailing Address - Fax:602-789-8389
Practice Address - Street 1:2510 W DUNLAP AVE STE 290
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2759
Practice Address - Country:US
Practice Address - Phone:602-789-0344
Practice Address - Fax:602-789-8389
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV26212207R00000X
AZ27792207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ648751Medicaid
AZZ126099Medicare PIN
AZ648751-01Medicaid
AZZ70554Medicare PIN