Provider Demographics
NPI:1194862730
Name:CLARK, JOHN FJ III
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FJ
Last Name:CLARK
Suffix:III
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:FRANCIS, JAMES
Other - Last Name:CLARK
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:255 CENTRAL PARK W
Mailing Address - Street 2:SUITE # 3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-4101
Mailing Address - Country:US
Mailing Address - Phone:212-769-0666
Mailing Address - Fax:212-799-6193
Practice Address - Street 1:255 CENTRAL PARK W
Practice Address - Street 2:SUITE # 3
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-4101
Practice Address - Country:US
Practice Address - Phone:212-769-0666
Practice Address - Fax:212-799-6193
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY160560-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00963231Medicaid
NYA64124Medicare UPIN
NY00963231Medicaid