Provider Demographics
NPI:1679575385
Name:CLARK, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:CLARK
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 1:325 MAIN ST
Mailing Address - Street 2:PO BOX 882
Mailing Address - City:PLAISTOW
Mailing Address - State:NH
Mailing Address - Zip Code:03865-3033
Mailing Address - Country:US
Mailing Address - Phone:603-382-5400
Mailing Address - Fax:603-382-4283
Practice Address - Street 1:785 CENTRAL RD
Practice Address - Street 2:
Practice Address - City:RYE BEACH
Practice Address - State:NH
Practice Address - Zip Code:03871-9005
Practice Address - Country:US
Practice Address - Phone:603-964-7740
Practice Address - Fax:603-964-7783
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
NH02894171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1048350001OtherDMERC
MA702777OtherHARVARD PILGRIM
MA803745OtherTUFTS
NH1207563Y0NH01OtherBLUE SHIELD NH
NH30437OtherCIGNA