Provider Demographics
NPI:1568569895
Name:CLARKE, GREGORY D (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7000
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-7000
Mailing Address - Country:US
Mailing Address - Phone:304-347-1290
Mailing Address - Fax:304-347-1397
Practice Address - Street 1:4522 MACCORKLE AVE, SE
Practice Address - Street 2:SUITE 3
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314
Practice Address - Country:US
Practice Address - Phone:304-720-7305
Practice Address - Fax:304-720-7310
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16242207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0110526000Medicaid
F18697Medicare UPIN
WVCL0682906Medicare ID - Type Unspecified