Provider Demographics
NPI:1174829923
Name:CLARKE, ROXANN VINELLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROXANN
Middle Name:VINELLE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 JOHN ST RM 1450
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-3122
Mailing Address - Country:US
Mailing Address - Phone:122-791-5700
Mailing Address - Fax:
Practice Address - Street 1:111 JOHN ST RM 1450
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038
Practice Address - Country:US
Practice Address - Phone:212-791-5700
Practice Address - Fax:212-791-5700
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006461213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY303480059Medicaid
NY303480059Medicaid