Provider Demographics
NPI:1366552747
Name:CLARK, JANE ROGERS (MD)
Entity type:Individual
Prefix:DR
First Name:JANE
Middle Name:ROGERS
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:15 WESTCLIFF RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-1409
Mailing Address - Country:US
Mailing Address - Phone:781-237-2544
Mailing Address - Fax:781-237-3225
Practice Address - Street 1:61 LINCOLN ST
Practice Address - Street 2:SUITE 109
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8264
Practice Address - Country:US
Practice Address - Phone:508-626-8956
Practice Address - Fax:508-875-4103
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57605207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3019748Medicaid
MAJ06301Medicare ID - Type Unspecified
MA3019748Medicaid