Provider Demographics
NPI:1831416569
Name:CLARK, BENNETT WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:WILLIAM
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 W BROAD ST STE 320
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 W BROAD ST STE 320
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3758
Practice Address - Country:US
Practice Address - Phone:475-251-8856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0075366207R00000X
CT54459208M00000X
MN62233207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist