Individual
DR. AUTUMN CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
1965 S FREMONT AVE, SUITE 330, SPRINGFIELD, MO 65804-2201
(417) 820-8180
(417) 820-8183
Mailing address
PO BOX 2580, SPRINGFIELD, MO 65801-2580
(417) 829-4620
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
0102201521
VA
2084P0800X
Psychiatry Physician
Primary
2010017178
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
183130003
—
AR
05
—
1912911090
—
MO
01
—
P00852000
RAILROAD MEDICARE #
MO
Enumeration date
07/27/2006
Last updated
05/02/2013
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