Provider Demographics
NPI:1760400071
Name:CLARK, NANCY ELLEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:ELLEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:61 BRETON HARBORS DRIVE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753
Mailing Address - Country:US
Mailing Address - Phone:973-632-9135
Mailing Address - Fax:
Practice Address - Street 1:25 MULE ROAD
Practice Address - Street 2:B9
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755
Practice Address - Country:US
Practice Address - Phone:732-966-1285
Practice Address - Fax:732-240-1441
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN05156213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ167255Medicare PIN
NYOP60171Medicare ID - Type Unspecified
NYU50723Medicare UPIN