Provider Demographics
NPI:1659397578
Name:CLARKSON, EARL I (DDS)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:I
Last Name:CLARKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 BROADWAY DEPARTMENT OF MANAGED CARE ROOM 2B230
Mailing Address - Street 2:WOODHULL MEDICAL & MENTAL HEALTH CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206
Mailing Address - Country:US
Mailing Address - Phone:718-963-8000
Mailing Address - Fax:718-630-3122
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:WOODHULL MEDICAL & MENTAL HEALTH CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206
Practice Address - Country:US
Practice Address - Phone:718-963-8000
Practice Address - Fax:718-250-6431
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0362551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00759251Medicaid
NY4572181OtherAETNA
NYP417983OtherOXFORD
NYD2E701Medicare UPIN
NYP417983OtherOXFORD