MEDICARE: ELIZABETH C CLARK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083P0901X	Public Health & General Preventive Medicine Physician	25MA08344100	NJ
2	207Q00000X	Family Medicine Physician	25MA08344100	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	35128	OTHER	IA	WELLMARK BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	P00790533	OTHER	NJ	RR MCR PTAN

General Provider Information

NPI Number	:	1558357996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH C CLARK MD

Provider Business Mailing Address
First Line	:	66 W GILBERT ST
Second Line	:	2ND FLOOR
City	:	TINTON FALLS
State	:	NJ
Zip	:	07701-4947
Country	:	US
Telephone Number	:	732-212-0051
Fax Number	:	732-212-0713

Provider Business Practice Location Address
First Line	:	317 GEORGE ST
Second Line	:	RWJ UNIVERSITY MEDICAL GROUP
City	:	NEW BRUNSWICK
State	:	NJ
Zip	:	08901-2008
Country	:	US
Telephone Number	:	732-235-8993
Fax Number	:	732-246-7317

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	04/11/2024

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