Provider Demographics
NPI:1164459319
Name:CLARKE, CLINTON EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:EDWARD
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 1:1300 N 12TH ST
Mailing Address - Street 2:SUITE 605
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2848
Mailing Address - Country:US
Mailing Address - Phone:602-839-2668
Mailing Address - Fax:602-839-2067
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:SUITE 605
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-839-2668
Practice Address - Fax:602-839-2067
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33324207QS0010X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ145980OtherMEDICARE PTAN
AZP00616915OtherRAILROAD MEDICARE
AZP00745791OtherRAILROAD MEDICARE 8/1/09
AZP00745791OtherRAILROAD MEDICARE 8/1/09
AZZ131411Medicare PIN
AZZ145980OtherMEDICARE PTAN
AZP00616915OtherRAILROAD MEDICARE
AZ120447Medicare PIN