Healthcare Provider Details

I. General information

NPI: 1417316274
Provider Name (Legal Business Name): CLARK DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 VICTORY BLVD
STATEN ISLAND NY
10301-3917
US

IV. Provider business mailing address

469 MORRIS AVE STE 3
ELIZABETH NJ
07208-2904
US

V. Phone/Fax

Practice location:
  • Phone: 718-448-4488
  • Fax:
Mailing address:
  • Phone: 732-574-1399
  • Fax: 908-512-7300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER DOCTOROFF
Title or Position: OWNER
Credential: D.O
Phone: 732-574-1399