Provider Demographics
NPI:1275852139
Name:CLARK, REBECCA ORTOLANO (MD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:ORTOLANO
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:MEGAN
Other - Last Name:ORTOLANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:107 N VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3336
Mailing Address - Country:US
Mailing Address - Phone:703-532-4446
Mailing Address - Fax:703-532-8426
Practice Address - Street 1:107 N VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3336
Practice Address - Country:US
Practice Address - Phone:703-532-4446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE267542080P0207X, 2080P0207X
VA0101277667208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics