Provider Demographics
NPI:1760434989
Name:CLARK, MORRIS (MD)
Entity Type:Individual
Prefix:
First Name:MORRIS
Middle Name:
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 1:11 GROVE ST
Mailing Address - Street 2:BOOTH HOUSE
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-3626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 GROVE ST
Practice Address - Street 2:BOOTH HOUSE
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-3626
Practice Address - Country:US
Practice Address - Phone:860-354-5511
Practice Address - Fax:860-350-3122
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT014985207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110000626Medicare ID - Type Unspecified
D02750Medicare UPIN