Provider Demographics
NPI:1356662498
Name:CLARKE, MICHAEL DAVID
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
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 1:8825 163RD ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4046
Mailing Address - Country:US
Mailing Address - Phone:718-739-0045
Mailing Address - Fax:718-739-0102
Practice Address - Street 1:8825 163RD ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4046
Practice Address - Country:US
Practice Address - Phone:718-739-0045
Practice Address - Fax:718-739-0102
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266675164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse