Individual
LEROY S CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
18344 CLARK STREET, SUITE 101, TARZANA, CA 91356
(818) 881-9811
(818) 881-1638
Mailing address
PO BOX 16699, IRVINE, CA 92623-6699
(949) 263-8620
(949) 263-1639
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
G14247
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00G142470
BLUE SHIELD
CA
05
—
00G142470
—
CA
Enumeration date
06/06/2006
Last updated
11/27/2007
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