Provider Demographics
NPI:1609142793
Name:CLAR, MIA KYONG JU (MD)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:KYONG JU
Last Name:CLAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:KYONG JU
Other - Last Name:BARNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:18 BEATRICE LN
Mailing Address - Street 2:
Mailing Address - City:OLD BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11804-1002
Mailing Address - Country:US
Mailing Address - Phone:214-315-7830
Mailing Address - Fax:
Practice Address - Street 1:865 NORTHERN BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5335
Practice Address - Country:US
Practice Address - Phone:516-708-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278962207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine