Provider Demographics
NPI:1346410107
Name:CLARKE, STEPHEN MARK (RD)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MARK
Last Name:CLARKE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 DEHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:PENNDEL
Mailing Address - State:PA
Mailing Address - Zip Code:19047-5208
Mailing Address - Country:US
Mailing Address - Phone:215-752-1802
Mailing Address - Fax:215-752-1802
Practice Address - Street 1:28 DEHAVEN AVE
Practice Address - Street 2:
Practice Address - City:PENNDEL
Practice Address - State:PA
Practice Address - Zip Code:19047-5208
Practice Address - Country:US
Practice Address - Phone:215-752-1802
Practice Address - Fax:215-752-1802
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-08
Last Update Date:2008-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000171133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001514652-0001Medicaid