Provider Demographics
NPI:1346225695
Name:CLARKE, MARK GREGORY
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GREGORY
Last Name:CLARKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:216 MASON AVE
Practice Address - Street 2:
Practice Address - City:CAPE CHARLES
Practice Address - State:VA
Practice Address - Zip Code:23310-3200
Practice Address - Country:US
Practice Address - Phone:757-331-1422
Practice Address - Fax:757-331-1624
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1346225695Medicaid
VA1346225695Medicaid
VAVV8544AMedicare PIN
VAP01132926Medicare PIN