Provider Demographics
NPI:1164534624
Name:CLARK, MARILYN R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:R
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:30 NORTHAMPTON STREET
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4010
Mailing Address - Country:US
Mailing Address - Phone:617-433-9601
Mailing Address - Fax:617-445-6538
Practice Address - Street 1:30 NORTHAMPTON STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4010
Practice Address - Country:US
Practice Address - Phone:617-433-9601
Practice Address - Fax:617-445-6538
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44535207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6168213Medicaid
MAE78546Medicare UPIN
MAM11939Medicare ID - Type Unspecified