| Doctor Name: | JUSTIN S CLARK |
| NPI Number: | 1033146634 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | 51149-20 |
| Business Practice Address: | 3001 Green Bay Rd North Chicago, IL - 600643048 |
| Business Phone Number: | 2246101197 |
| Business Fax Number: | |
| Mailing Address: | 3001 Green Bay Rd, NORTH CHICAGO |
| State: | IL |
| Postal Code: | 600643048 |
| Phone Number: | 2246101197 |
| Fax Number: | |
| NPI Enumeration Date: | 06/27/2006 |
| NPI Last Update Date: | 02/16/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 51149-20 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | WI |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |