Provider Demographics
NPI:1962480459
Name:CLARK, JUSTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1638
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-1638
Mailing Address - Country:US
Mailing Address - Phone:207-777-4111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:99 CAMPUS AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6045
Practice Address - Country:US
Practice Address - Phone:207-782-5424
Practice Address - Fax:207-782-1136
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA215216208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery