Healthcare Provider Details

I. General information

NPI: 1497763171
Provider Name (Legal Business Name): ELAINE CLARKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 PORT RICHMOND AVENUE
STATEN ISLAND NY
10302-1701
US

IV. Provider business mailing address

235 PORT RICHMOND AVENUE
STATEN ISLAND NY
10302-1701
US

V. Phone/Fax

Practice location:
  • Phone: 718-924-2256
  • Fax: 718-442-0189
Mailing address:
  • Phone: 718-924-2256
  • Fax: 718-442-0189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number179996
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: