Provider Demographics
NPI:1033394580
Name:CLARKE, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 COLESVILLE RD
Mailing Address - Street 2:STE. 310
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3312
Mailing Address - Country:US
Mailing Address - Phone:301-587-4585
Mailing Address - Fax:301-585-4564
Practice Address - Street 1:8401 COLESVILLE RD
Practice Address - Street 2:STE. 310
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3312
Practice Address - Country:US
Practice Address - Phone:301-587-4585
Practice Address - Fax:301-585-4564
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0044311174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCF60848Medicare UPIN