MEDICARE: DR. RICHARD CLARK M.D.

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	207N00000X	Dermatology Physician	181488	NY

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

General Provider Information

NPI Number	:	1700825429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD CLARK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1559
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11790-0989
Country	:	US
Telephone Number	:	631-444-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	181 N BELLE MEAD RD
Second Line	:
City	:	EAST SETAUKET
State	:	NY
Zip	:	11733-3495
Country	:	US
Telephone Number	:	631-444-4200
Fax Number	:

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

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	12/06/2013

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