Provider Demographics
NPI:1104829688
Name:CLARKE, STANLEY D (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:D
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15055 COLLECTION CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60693-0001
Mailing Address - Country:US
Mailing Address - Phone:256-383-3325
Mailing Address - Fax:480-212-8451
Practice Address - Street 1:1110 S JACKSON HWY
Practice Address - Street 2:
Practice Address - City:SHEFFIELD
Practice Address - State:AL
Practice Address - Zip Code:35660-5747
Practice Address - Country:US
Practice Address - Phone:256-383-5211
Practice Address - Fax:256-381-1517
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000190492085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051504899OtherAL BCBS
AL051504900OtherAL BCBS
AL529909740Medicaid
AL103413Medicaid
AL515-45255OtherBCBS AL
AL515-45256OtherBCBS AL
AL103086Medicaid
AL009973900Medicaid
AL051550973Medicaid
AL515-45256OtherBCBS AL
G08665Medicare UPIN
AL103413Medicaid
AL510I920007Medicare PIN