1285714907 NPI number — PAUL R CLARK ORTHOTIST

Table of content: PAUL R CLARK ORTHOTIST (NPI 1285714907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285714907 NPI number — PAUL R CLARK ORTHOTIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
PAUL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ORTHOTIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285714907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 850164
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRAINTREE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02185-0164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-254-6437
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 POND AVE
Provider Second Line Business Practice Location Address:
SUITE 107B
Provider Business Practice Location Address City Name:
BROOKLINE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02445-7163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-254-6437
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2006

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: 332BC3200X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1537369 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 375354 . This is a "DME" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com