Healthcare Provider Details

I. General information

NPI: 1508056441
Provider Name (Legal Business Name): DEDRIC J CLARKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 PRYTANIA ST STE 400
NEW ORLEANS LA
70115-3768
US

IV. Provider business mailing address

3600 PRYTANIA ST STE 35
NEW ORLEANS LA
70115-3678
US

V. Phone/Fax

Practice location:
  • Phone: 504-897-8276
  • Fax: 504-897-8336
Mailing address:
  • Phone: 504-897-8412
  • Fax: 504-249-5311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number200764
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberMD.200764
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: