Healthcare Provider Details

I. General information

NPI: 1558357996
Provider Name (Legal Business Name): ELIZABETH C CLARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 GEORGE ST RWJ UNIVERSITY MEDICAL GROUP
NEW BRUNSWICK NJ
08901-2008
US

IV. Provider business mailing address

66 W GILBERT ST 2ND FLOOR
TINTON FALLS NJ
07701-4947
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-8993
  • Fax: 732-246-7317
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number25MA08344100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA08344100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: