Healthcare Provider Details

I. General information

NPI: 1346780905
Provider Name (Legal Business Name): CLARKE NEUROLOGY A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NEWPORT CENTER DR STE 310
NEWPORT BEACH CA
92660-7601
US

IV. Provider business mailing address

400 NEWPORT CENTER DR STE 310
NEWPORT BEACH CA
92660-7601
US

V. Phone/Fax

Practice location:
  • Phone: 949-701-2811
  • Fax:
Mailing address:
  • Phone: 949-701-2811
  • Fax: 949-644-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberA72641
License Number StateCA

VIII. Authorized Official

Name: DR. TERYN BREE CLARKE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-701-2811