Provider Demographics
NPI:1699712000
Name:CLARKE, RONALD LARSON (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:LARSON
Last Name:CLARKE
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 1:5178 NELCO CT
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-2906
Mailing Address - Country:US
Mailing Address - Phone:503-557-9384
Mailing Address - Fax:
Practice Address - Street 1:14279 GLEN OAK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-8008
Practice Address - Country:US
Practice Address - Phone:503-657-7629
Practice Address - Fax:503-557-8651
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16593208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR009496Medicaid
OR67972000OtherBCBS
E59243Medicare UPIN