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General NPI Number Information
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NPI Number | 1417316274
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Entity Type | Organization
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Legal Business Name | CLARK DERMATOLOGY, LLC
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Dates
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Enumeration Date | 02/22/2016
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Last Update Date | 05/05/2025
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Provider Practice Location Address
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Address Line | 1324 VICTORY BLVD
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City | STATEN ISLAND
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State | NY
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Zip | 10301-3917
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Country | US
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Telephone | 718-448-4488
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Fax |
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Provider Business Mailing Address
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Address Line | 469 MORRIS AVE STE 3
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City | ELIZABETH
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State | NJ
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Zip | 07208-2904
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Country | US
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Telephone | 732-574-1399
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Fax | 908-512-7300
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Authorized Official
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Title or Position | OWNER
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Name | ALEXANDER DOCTOROFF
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Credential | D.O
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Telephone | 732-574-1399
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207ND0900X
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Taxonomy Name | Dermatopathology Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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