Provider Demographics
NPI:1417316274
Name:CLARK DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:CLARK DERMATOLOGY, LLC
Other - Org Name:METROPOLITAN DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOCTOROFF
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-574-1399
Mailing Address - Street 1:1075 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1116
Mailing Address - Country:US
Mailing Address - Phone:732-574-1399
Mailing Address - Fax:732-574-1433
Practice Address - Street 1:1324 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3917
Practice Address - Country:US
Practice Address - Phone:718-448-4488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2820421207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400133625Medicare PIN