Provider Demographics
NPI:1053752675
Name:VAN DEN BERGHE, CLARK (MD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:VAN DEN BERGHE
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 1:269 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1314
Mailing Address - Country:US
Mailing Address - Phone:781-581-3900
Mailing Address - Fax:781-598-1050
Practice Address - Street 1:269 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1314
Practice Address - Country:US
Practice Address - Phone:781-596-2502
Practice Address - Fax:781-596-3966
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA256393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine