Provider Demographics
NPI:1407858848
Name:CLARK, BERNARD A (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:A
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 1:1000 ASYLUM AVE
Mailing Address - Street 2:SUITE 2109A
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1770
Mailing Address - Country:US
Mailing Address - Phone:860-714-6581
Mailing Address - Fax:860-714-8311
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:CARDIOLOGY
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-4161
Practice Address - Fax:860-714-8001
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024602207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001246025Medicaid
CTD03016Medicare UPIN
CT060001159Medicare ID - Type Unspecified