Provider Demographics
NPI:1376630541
Name:CLARK, CANTWELL V (MD)
Entity Type:Individual
Prefix:DR
First Name:CANTWELL
Middle Name:
Last Name:CLARK
Suffix:V
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 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DHMC. DEPARTMENT OF ANESTHESIOLOGY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:DARTMOUTH-HITCHCOCK CLINIC
Practice Address - Street 2:1 MEDICAL CENTER DRIVE
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756
Practice Address - Country:US
Practice Address - Phone:603-650-5922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12598207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011289Medicaid
NH30201138Medicaid
NHHX3984Medicare PIN
B97896Medicare UPIN