Provider Demographics
NPI:1093186702
Name:CLARK PEDIATRICS, LLC
Entity Type:Organization
Organization Name:CLARK PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DULCE
Authorized Official - Middle Name:SUAPENGCO
Authorized Official - Last Name:SAMONTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-574-9444
Mailing Address - Street 1:480 OAK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-2124
Mailing Address - Country:US
Mailing Address - Phone:732-574-9444
Mailing Address - Fax:
Practice Address - Street 1:480 OAK RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-2124
Practice Address - Country:US
Practice Address - Phone:732-574-9444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04400000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty