Provider Demographics
NPI:1972634897
Name:CLARK, LORI LYNN
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23521 PASEO DE VALENCIA
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3107
Mailing Address - Country:US
Mailing Address - Phone:949-588-7262
Mailing Address - Fax:949-588-7260
Practice Address - Street 1:23521 PASEO DE VALENCIA
Practice Address - Street 2:SUITE 108
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3107
Practice Address - Country:US
Practice Address - Phone:949-588-7262
Practice Address - Fax:949-588-7260
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82608207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A82608OtherMEDICAL LICENSE
CAI11985Medicare UPIN