Dwayne Charles Clark, MD

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

48855 Issued in WI

Practice address

723 Park Ridge LN
N Fond Du Lac, WI 54937-1385

Phone

(920) 926-8600

Fax

(920) 926-8650

NPI assigned

Jan 30, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in WI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Family Practice

Education

Duke University School of Medicine, 1994

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Agnesian Healthcare IncGroup PAC ID 1658289624, 392 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Agnesian Healthcare, Inc

  • General Acute Care Hospital
  • Fond Du Lac, WI
  • NPI 1346228541
  Medicare reassignment Care Compare group NPD
• Agnesian Healthcare Inc

  • Community/Retail Pharmacy
  • Waupun, WI
  • NPI 1366417917
  NPD
• Agnesian Healthcare Inc

  • Family Medicine Physician
  • Fond Du Lac, WI
  • NPI 1730162991
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1138579200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1603843200000",
    "number": "1184695975",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "420 E DIVISION ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354560",
            "telephone_number": "920-926-8340",
            "fax_number": "920-926-8370"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "723 PARK RIDGE LN",
            "city": "N FOND DU LAC",
            "state": "WI",
            "postal_code": "549371385",
            "telephone_number": "920-926-8600",
            "fax_number": "920-926-8650"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "DWAYNE",
        "middle_name": "CHARLES",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-01-30",
        "last_updated": "2020-10-28",
        "certification_date": "2020-10-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "48855",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "P00319962",
            "state": "WI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "dclark330543@direct-ehr-ssmhc.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "dclark330543@direct-ehr-ssmhc.com",
            "address_1": "723 Park Ridge Ln",
            "city": "N Fond Du Lac",
            "state": "WI",
            "country_code": "US",
            "postal_code": "549371385",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://fhir.ssmhc.com/fhir/api/FHIR/DSTU2/",
            "affiliation": "N",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "FHIR API",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CCD",
            "address_1": "723 Park Ridge Ln",
            "city": "N Fond Du Lac",
            "state": "WI",
            "country_code": "US",
            "postal_code": "549371385",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Agnesian Healthcare Inc
• Karly K Boegel, APNP
• Daniel R Johnson, DO
• Alexis Lynn Moore, FNP-C
• Moriah Quist
• Releve Physical Therapy LLC
• Kumi D Swart, D.O.

• Family Medicine Physician in N Fond Du Lac, WI
• Providers in N Fond Du Lac, WI by specialty
• Family Medicine Physician in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.