Provider Demographics
NPI:1346368925
Name:CLARCQ, LISA A (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:CLARCQ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4974
Mailing Address - Country:US
Mailing Address - Phone:207-873-1098
Mailing Address - Fax:207-861-5461
Practice Address - Street 1:149 NORTH ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4974
Practice Address - Country:US
Practice Address - Phone:207-873-1098
Practice Address - Fax:207-861-5461
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1610207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME154420000Medicaid
MEG86555Medicare UPIN
ME154420000Medicaid
MEMM760601Medicare PIN
MEP00255955Medicare PIN