Healthcare Provider Details

I. General information

NPI: 1164459319
Provider Name (Legal Business Name): CLINTON EDWARD CLARKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST SUITE 605
PHOENIX AZ
85006-2848
US

IV. Provider business mailing address

1300 N 12TH ST SUITE 605
PHOENIX AZ
85006-2848
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-2668
  • Fax: 602-839-2067
Mailing address:
  • Phone: 602-839-2668
  • Fax: 602-839-2067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number33324
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number33324
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: