1275852139 NPI number — DR. REBECCA ORTOLANO CLARK MD

Table of content: DR. REBECCA ORTOLANO CLARK MD (NPI 1275852139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275852139 NPI number — DR. REBECCA ORTOLANO CLARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
REBECCA
Provider Middle Name:
ORTOLANO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ORTOLANO
Provider Other First Name:
REBECCA
Provider Other Middle Name:
MEGAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275852139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4954 N PALMER RD
Provider Second Line Business Mailing Address:
PED HEME/ONC, BLDG 19, 4TH FLR, WALTER REED NATIONAL MI
Provider Business Mailing Address City Name:
BETHESDA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20889-5630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-400-1663
Provider Business Mailing Address Fax Number:
301-400-1662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4954 N PALMER RD
Provider Second Line Business Practice Location Address:
PED HEME/ONC, BLDG 19, 4TH FLR, WALTER REED NATIONAL MI
Provider Business Practice Location Address City Name:
BETHESDA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20889-1000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-400-1663
Provider Business Practice Location Address Fax Number:
301-400-1663
Provider Enumeration Date:
05/18/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  26754 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0207X , with the licence number: 26754 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)