Provider Demographics
NPI:1881626042
Name:CLARK, CHERYL RENEE (MD, MS, SD)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD, MS, SD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 TREMONT ST
Mailing Address - Street 2:CENTER FOR COMMUNITY HEALTH AND HEALTH EQUITY
Mailing Address - City:ROXBURY CROSSING
Mailing Address - State:MA
Mailing Address - Zip Code:02120-1613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1620 TREMONT ST
Practice Address - Street 2:CENTER FOR COMMUNITY HEALTH AND HEALTH EQUITY
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-1613
Practice Address - Country:US
Practice Address - Phone:617-732-5759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA218079207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine