Provider Demographics
NPI:1346206950
Name:CLARKE, FRED (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MARCUS DR
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4230
Mailing Address - Country:US
Mailing Address - Phone:631-391-7889
Mailing Address - Fax:631-454-4163
Practice Address - Street 1:20016 HOLLIS AVENUE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11412
Practice Address - Country:US
Practice Address - Phone:718-736-8204
Practice Address - Fax:718-736-8505
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY206376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01862739Medicaid
NY03595KMedicare PIN
NY01862739Medicaid