Provider Demographics
NPI:1275516676
Name:CLARKE, PETER DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:DOUGLAS
Last Name:CLARKE
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 1:75 FRANCIS ST
Mailing Address - Street 2:RADIOLOGY BRIGHAM & WOMENS HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-732-6505
Mailing Address - Fax:617-732-6336
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:RADIOLOGY BRIGHAM & WOMENS HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-732-8098
Practice Address - Fax:617-525-7333
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA543702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ05829OtherBLUE CROSS BLUE SHIELD
MA3013465Medicaid
MA076080OtherTUFTS HEALTH CARE
B97960Medicare ID - Type Unspecified
MAJ05829Medicare ID - Type Unspecified