Provider Demographics
NPI:1235202599
Name:CLARK, WILLIAM BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRUCE
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 LEW LOUDON ROAD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-5701
Mailing Address - Country:US
Mailing Address - Phone:518-783-1472
Mailing Address - Fax:518-783-1605
Practice Address - Street 1:585 LEW LOUDON ROAD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-5701
Practice Address - Country:US
Practice Address - Phone:518-783-1472
Practice Address - Fax:518-783-1605
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114221207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00798590Medicaid
D78428Medicare UPIN
52188BMedicare ID - Type Unspecified