Provider Demographics
NPI:1588762801
Name:CLARK, RONALD FREDERICK
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:FREDERICK
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NEWINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-2310
Mailing Address - Country:US
Mailing Address - Phone:860-236-3364
Mailing Address - Fax:860-236-3364
Practice Address - Street 1:5 NEWINGTON ROAD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-2310
Practice Address - Country:US
Practice Address - Phone:860-236-3364
Practice Address - Fax:860-236-3364
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000210111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT04046611Medicaid
CT050000210CT01OtherBCBS