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NPI Code Detail

MEDICARE: ELSA JIMENEZ CLARK M.D.

MEDICARE: ELSA JIMENEZ 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
1207R00000XInternal Medicine Physician186750NY

General Provider Information

NPI Number : 1770589343
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELSA JIMENEZ CLARK M.D.
Provider Business Mailing Address
First Line : 1259 WANTAGH AVE
Second Line :
City : WANTAGH
State : NY
Zip : 11793-2205
Country : US
Telephone Number : 516-221-7971
Fax Number : 516-221-8117
Provider Business Practice Location Address
First Line : 1259 WANTAGH AVE
Second Line :
City : WANTAGH
State : NY
Zip : 11793-2205
Country : US
Telephone Number : 516-221-7971
Fax Number : 516-221-8117
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/28/2005
Last Update Date : 06/24/2008

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