Provider Demographics
NPI:1093939647
Name:CLARKE, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 FAIRMOUNT AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5494
Mailing Address - Country:US
Mailing Address - Phone:410-927-8768
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:19785 CRYSTAL ROCK DR STE 311
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-4732
Practice Address - Country:US
Practice Address - Phone:301-540-3529
Practice Address - Fax:301-540-3623
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD161762ZD6TMedicare PIN