Provider Demographics
NPI:1154436830
Name:SISK, CLARK EDMUND (MD)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:EDMUND
Last Name:SISK
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 1:3600 N INTERSTATE AVE
Mailing Address - Street 2:KAISER, DERMATOLOGY, CENTRAL INTERSTATE MEDICAL OFFICE
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1106
Mailing Address - Country:US
Mailing Address - Phone:503-331-3060
Mailing Address - Fax:503-290-2930
Practice Address - Street 1:3600 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1106
Practice Address - Country:US
Practice Address - Phone:503-331-3033
Practice Address - Fax:503-280-2930
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR MD12188207N00000X
WAWA MD00035021207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology