Provider Demographics
NPI:1558357996
Name:CLARK, ELIZABETH C (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:66 W GILBERT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4947
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:317 GEORGE ST
Practice Address - Street 2:RWJ UNIVERSITY MEDICAL GROUP
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-2008
Practice Address - Country:US
Practice Address - Phone:732-235-8993
Practice Address - Fax:732-246-7317
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2024-04-11
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA083441002083P0901X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0295998Medicaid
IA35128OtherWELLMARK BCBS
NJ0201120Medicaid
NJP00790533OtherRR MCR PTAN
NJP00790533OtherRR MCR PTAN
IA35128OtherWELLMARK BCBS
IA0295998Medicaid
NJ158167A02Medicare PIN