Provider Demographics
NPI:1851412829
Name:CLARKE, BRETT M (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:M
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 E 30TH ST
Mailing Address - Street 2:BLDG D-102
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8990
Mailing Address - Country:US
Mailing Address - Phone:505-327-4429
Mailing Address - Fax:
Practice Address - Street 1:2300 E 30TH ST
Practice Address - Street 2:BLDG D-102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-327-4429
Practice Address - Fax:505-327-4420
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
NMMD2008-0042207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program