Kenneth Clark, M.D.

Primary specialty

SpecialistTaxonomy code 174400000X

License

22673 Issued in WI

Practice address

2025 E Newport Ave
Milwaukee, WI 53211-2906

Phone

(414) 961-3841

NPI assigned

Dec 1, 2005

Reactivated

Apr 5, 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

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

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.

• Ascension Medical Group-Southeast Wisconsin Inc

  • Internal Medicine Physician
  • Glendale, WI
  • NPI 1609881077
  NPD (past)
• Commonwealth Medical Group, LLC

  • Internal Medicine Physician
  • West Allis, WI
  • NPI 1477500361
  NPD (past)
• Wisconsin Radiology Specialists, S C

  • Specialist
  • Mequon, WI
  • NPI 1568446003
  NPD (past)

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

{
    "created_epoch": "1133395200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1186963200000",
    "number": "1356325518",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "500 W BROWN DEER RD",
            "address_2": "SUITE 202",
            "city": "BAYSIDE",
            "state": "WI",
            "postal_code": "532171627"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2025 E NEWPORT AVE",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532112906",
            "telephone_number": "414-961-3841"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "KENNETH",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-12-01",
        "last_updated": "2007-08-13",
        "deactivation_date": "2005-12-09",
        "reactivation_date": "2006-04-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "WI",
            "license": "22673",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Anaddia S Clark
• Candace Ann Clark, PA
• Courtney Marie Clark, MS, LPC
• Delna Lee Clark, LPN
• Grant Brierton Clark
• Lindsey Margaret Clark, PHARM.D.
• Nicole Clark, APSW, CSAC
• Rita T Clark, P.T.A.
• Callisia Clarke, MD
• Malorie Sue Ann Clasen, LPC-IT, NCC

• Specialist in Milwaukee, WI
• Providers in Milwaukee, WI by specialty
• Specialist in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 13, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.