=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841384039
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN J. CLARKE, D.P.M.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 01/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 HAYES AVE
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-2755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-332-8105
-----------------------------------------------------
Fax | 419-332-8608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 HAYES AVE
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-2755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-332-8105
-----------------------------------------------------
Fax | 419-332-8608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN J CLARKE
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 419-332-8105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 1898
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------