Provider Demographics
NPI:1285714907
Name:CLARK, PAUL R (ORTHOTIST)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:ORTHOTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850164
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02185-0164
Mailing Address - Country:US
Mailing Address - Phone:781-254-6437
Mailing Address - Fax:
Practice Address - Street 1:33 POND AVE
Practice Address - Street 2:SUITE 107B
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7163
Practice Address - Country:US
Practice Address - Phone:781-254-6437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1537369Medicaid
MA375354OtherDME
MA0561800001Medicare NSC