Provider Demographics
NPI:1356760938
Name:DUMONTIER, CLARK
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:DUMONTIER
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 1:150 S HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4817
Mailing Address - Country:US
Mailing Address - Phone:920-740-2790
Mailing Address - Fax:
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:920-740-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA274719207R00000X, 207RG0300X
MA260502207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine