Provider Demographics
NPI:1902874456
Name:CLARK, BRENT (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
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 1:9816 FRANKSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15235-1643
Mailing Address - Country:US
Mailing Address - Phone:412-243-4525
Mailing Address - Fax:412-243-3784
Practice Address - Street 1:9816 FRANKSTOWN RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15235-1643
Practice Address - Country:US
Practice Address - Phone:412-243-4525
Practice Address - Fax:412-243-3784
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042270L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA617289OtherHIGHMARK
1203799OtherFIRST HEALTH
3767OtherHEALTHAMERICA
64166OtherUNITEDMINEWORKERAMERICA
PA47630OtherAETNA
PA60049OtherUNISON ADVANTAGE
PA1010600OtherGATEWAY HEALTH PLAN
PA251661326OtherADVANTRA
120315400OtherUSDEPTOLABOR WORKERSCOMP
12627OtherELDER HEALTH
PA250326OtherUPMC
PA251661326OtherHEALTHAMERICA
PA0012387920002Medicaid
PA0012387920005Medicaid
PA0012387920006Medicaid
PA251661326OtherHEALTHAMERICA
PA617289Medicare ID - Type Unspecified