Provider Demographics
NPI:1104174846
Name:CLARK, MARY E (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:HUNNEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:215 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05009-0001
Mailing Address - Country:US
Mailing Address - Phone:508-776-8014
Mailing Address - Fax:
Practice Address - Street 1:163 VETERANS DRIVE
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05009-4728
Practice Address - Country:US
Practice Address - Phone:508-776-8014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE27610207ZP0102X
RILP05113207ZP0102X
MA282335207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology