Provider Demographics
NPI:1366500712
Name:CLARK, ALAN B (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:B
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ALAN
Other - Middle Name:B
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PA,
Mailing Address - Street 1:240 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-3313
Mailing Address - Country:US
Mailing Address - Phone:973-674-3500
Mailing Address - Fax:973-678-6319
Practice Address - Street 1:240 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-3313
Practice Address - Country:US
Practice Address - Phone:973-674-3500
Practice Address - Fax:973-678-6319
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA206812084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ280330501OtherMEDICAID GROUP
NJ5069505Medicaid
NJ135853OtherMEDICARE GROUP
NJ135853OtherMEDICARE GROUP
NJ280330501OtherMEDICAID GROUP