Provider Demographics
NPI:1477555845
Name:CLARKE, DWIGHT (MD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
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:PO BOX 39179
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85069-9179
Mailing Address - Country:US
Mailing Address - Phone:602-395-0718
Mailing Address - Fax:602-277-8146
Practice Address - Street 1:340 E PALM LN
Practice Address - Street 2:SUITE A260
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4603
Practice Address - Country:US
Practice Address - Phone:602-254-1136
Practice Address - Fax:602-279-1720
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32231207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ859142Medicaid
AZAZ0756690OtherBLUE CROSS BLUE SHIELD
AZI04896Medicare UPIN
AZ859142Medicaid