Provider Demographics
NPI:1477502128
Name:CLARKE, MARY EVADNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:EVADNE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 ROSENEATH RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-1515
Mailing Address - Country:US
Mailing Address - Phone:804-598-5503
Mailing Address - Fax:804-359-5162
Practice Address - Street 1:DMCC
Practice Address - Street 2:
Practice Address - City:STATE FARM
Practice Address - State:VA
Practice Address - Zip Code:23160
Practice Address - Country:US
Practice Address - Phone:804-598-5503
Practice Address - Fax:804-403-3404
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049706207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine