Provider Demographics
NPI:1497763171
Name:CLARKE, ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
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 1:235 PORT RICHMOND AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1701
Mailing Address - Country:US
Mailing Address - Phone:718-924-2256
Mailing Address - Fax:718-442-0189
Practice Address - Street 1:235 PORT RICHMOND AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1701
Practice Address - Country:US
Practice Address - Phone:718-924-2256
Practice Address - Fax:718-442-0189
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179996208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY179996POtherHEALTHCARE PARTNERS
NY017999601OtherNEIGHBORHOOD
NY110403000000OtherFIDELIS CARE
NYP4364657OtherUNITEDHEALTH CARE OXFORD
NY01178778OtherAMERIGROUP