Provider Demographics
NPI:1164625653
Name:CLARK, JOHN GLENN
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GLENN
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 WHISKEAG RD
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-4127
Mailing Address - Country:US
Mailing Address - Phone:909-435-0066
Mailing Address - Fax:
Practice Address - Street 1:111 WHISKEAG RD
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-4127
Practice Address - Country:US
Practice Address - Phone:909-435-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016756207X00000X
CAA60772207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEH19089Medicare UPIN
MEME1303Medicare ID - Type Unspecified