Provider Demographics
NPI:1437159795
Name:CLARK, BRIAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:22 WEST ST STE 25
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01527-2677
Mailing Address - Country:US
Mailing Address - Phone:508-917-6720
Mailing Address - Fax:508-917-6721
Practice Address - Street 1:22 WEST ST STE 25
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:MA
Practice Address - Zip Code:01527-2677
Practice Address - Country:US
Practice Address - Phone:508-917-6720
Practice Address - Fax:508-917-6721
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA226853207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2112191Medicaid
MAA39571Medicare ID - Type Unspecified
MA2112191Medicaid