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NPI Code Detail

MEDICARE: ROGER CLARK

MEDICARE: ROGER CLARK
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
1390200000XStudent in an Organized Health Care Education/Training ProgramNY

General Provider Information

NPI Number : 1922640721
Entity Type Code : Individual
Provider Name (Legal Business Name) : ROGER CLARK
Provider Business Mailing Address
First Line : 2040 GLEASON AVE APT 2K
Second Line :
City : BRONX
State : NY
Zip : 10472-5282
Country : US
Telephone Number : 646-939-0733
Fax Number :
Provider Business Practice Location Address
First Line : 160 CONVENT AVE
Second Line : HARRIS HALL H-15
City : NEW YORK
State : NY
Zip : 10031-9198
Country : US
Telephone Number : 212-650-7745
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/13/2019
Last Update Date : 10/13/2019

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Directions to “ ROGER CLARK ” Practice Location

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