Provider Demographics
NPI:1851577795
Name:PAUL R CLARK
Entity Type:Organization
Organization Name:PAUL R CLARK
Other - Org Name:CLARK ORTHOPEDICS CO.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHOTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-787-0504
Mailing Address - Street 1:P O BOX 850164
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02185
Mailing Address - Country:US
Mailing Address - Phone:617-787-0504
Mailing Address - Fax:
Practice Address - Street 1:1 BRAINTREE ST
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-1602
Practice Address - Country:US
Practice Address - Phone:617-787-0504
Practice Address - Fax:781-356-2074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA670375OtherTUFT'S NAVIGATOR
MA670375OtherTUFT'S HEALTH INSURANCE
MA1537369Medicaid
MA375354OtherBLUE CROSS/BLUE SHIELD OF MASSACHUSETTS
MA670375OtherTUFT'S TOTAL HEALTH PLAN
MA375354OtherBLUE CROSS/BLUE SHIELD OF MASSACHUSETTS
MA670375OtherTUFT'S HEALTH INSURANCE
MA=========OtherAETNA HEATH INSURANCE
MA670375OtherTUFT'S NAVIGATOR
MA=========OtherCIGNA HEALTH INSURANCE
MA1537369Medicaid