Provider Demographics
NPI:1760407076
Name:CLARKE, DIANE P (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:P
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:801 NORTHPOINT PKWY 83
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-1812
Mailing Address - Country:US
Mailing Address - Phone:561-721-6431
Mailing Address - Fax:561-721-6432
Practice Address - Street 1:801 NORTHPOINT PKWY
Practice Address - Street 2:SUITE 83
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-1973
Practice Address - Country:US
Practice Address - Phone:561-721-6431
Practice Address - Fax:561-721-6432
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME80513207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266645600Medicaid
FLU0463ZMedicare ID - Type Unspecified
FL052033195OtherMEDIPASS
FLH81117Medicare UPIN