Healthcare Provider Details

I. General information

NPI: 1770841611
Provider Name (Legal Business Name): SHANA CLARKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2012
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7403 COMMONWEALTH BLVD BLDG 55
BELLEROSE NY
11426-1839
US

IV. Provider business mailing address

7403 COMMONWEALTH BLVD BLDG 55
BELLEROSE NY
11426-1839
US

V. Phone/Fax

Practice location:
  • Phone: 718-264-4535
  • Fax:
Mailing address:
  • Phone: 718-264-4535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number292253
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number292253
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: