=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588792501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETA CLARKSON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 N WASHINGTON ST
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19801-1509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-655-7110
-----------------------------------------------------
Fax | 302-655-6185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 ASHFORD DR
-----------------------------------------------------
City | CHADDS FORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19317-8230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | C1-0007596
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------