Provider Demographics
NPI:1982781258
Name:CLARK, ROBERT J (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1228
Mailing Address - Country:US
Mailing Address - Phone:617-479-2400
Mailing Address - Fax:617-479-2828
Practice Address - Street 1:69 WILLARD ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1228
Practice Address - Country:US
Practice Address - Phone:617-479-2400
Practice Address - Fax:617-479-2828
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2111111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA792893OtherTUFTS
MA351264OtherHARVARD PILGRIM
MA0022022OtherNHP
MAY36490OtherBC/BS
MAY45114Medicare ID - Type Unspecified