Healthcare Provider Details

I. General information

NPI: 1558289777
Provider Name (Legal Business Name): DAVID CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WARING AVE
BRONX NY
10469-6331
US

IV. Provider business mailing address

1800 WARING AVE
BRONX NY
10469-6331
US

V. Phone/Fax

Practice location:
  • Phone: 718-379-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberP142865
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: