Provider Demographics
NPI:1043223324
Name:CLARK, MOLLY ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-1905
Mailing Address - Country:US
Mailing Address - Phone:781-263-0033
Mailing Address - Fax:781-263-9145
Practice Address - Street 1:30 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-1905
Practice Address - Country:US
Practice Address - Phone:781-263-0033
Practice Address - Fax:781-263-9145
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA55906174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3006921Medicaid
MAJ05959Medicare ID - Type Unspecified
MA3006921Medicaid