Provider Demographics
NPI:1619102928
Name:DUFFY, CLARK
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:DUFFY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 RUTH ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4017
Mailing Address - Country:US
Mailing Address - Phone:920-253-7282
Mailing Address - Fax:
Practice Address - Street 1:914 NW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3039
Practice Address - Country:US
Practice Address - Phone:971-244-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-16
Last Update Date:2009-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist