Provider Demographics
NPI:1891013967
Name:CLARK, ALLEN RICHARD (MD)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:RICHARD
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 1:121 MEDICAL CENTER DR STE 2700
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2669
Mailing Address - Country:US
Mailing Address - Phone:207-721-8700
Mailing Address - Fax:207-536-6719
Practice Address - Street 1:121 MEDICAL CENTER DR STE 2700
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2669
Practice Address - Country:US
Practice Address - Phone:207-721-8700
Practice Address - Fax:207-536-6719
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD29198207V00000X, 207VG0400X
IN01074111207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01074111AOtherLICENSE
IN201233020Medicaid
FC4643866OtherDEA
FC4643866OtherDEA