Individual
KEITH FREDRICK CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD PHD
Contact information
Practice address
535 NW 9TH ST, SUITE 300, OKLAHOMA CITY, OK 73102-1070
(405) 272-6027
(405) 272-8315
Mailing address
535 NW 9TH ST, SUITE 300, OKLAHOMA CITY, OK 73102-1070
(405) 272-6027
(405) 272-8315
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
14220
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100823600B
—
OK
05
—
157107001
—
AR
01
—
2994975
AETNA US HEALTHCARE
—
01
—
731461178005
TRICARE
—
01
—
A0209Z
PPO OKLAHOMA
—
01
—
P00075512
RR MEDICARE
—
Enumeration date
04/08/2006
Last updated
10/18/2020
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