Healthcare Provider Details

I. General information

NPI: 1295760908
Provider Name (Legal Business Name): MAIYA YETUNDE ELON CLARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 UNIVERSITY BLVD W SUITE 325
SILVER SPRING MD
20901-1948
US

IV. Provider business mailing address

1507 KEARNEY ST NE
WASHINGTON DC
20017-2959
US

V. Phone/Fax

Practice location:
  • Phone: 301-593-5440
  • Fax: 301-593-5501
Mailing address:
  • Phone: 202-832-8152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0061964
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: