Provider Demographics
NPI:1881671766
Name:CLARKE, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
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 1:237 WILLIAM HOWARD TAFT RD
Mailing Address - Street 2:2ND FLOOR, CBO 2-3
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2610
Mailing Address - Country:US
Mailing Address - Phone:513-206-1120
Mailing Address - Fax:513-206-1122
Practice Address - Street 1:2123 AUBURN AVE
Practice Address - Street 2:SUITE 138
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-206-1120
Practice Address - Fax:512-206-1122
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069414207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
0659341OtherAETNA
OH64298508Medicaid
OHP00222905OtherRAILROAD MEDICARE
IN200076710Medicaid
311438871044OtherCARESOURCE MEDICAID
000000215174OtherANTHEM
283291OtherAMERIGROUP MEDICAID
KY64298508Medicaid
25-20465OtherUNITED
OH263070266OtherCARESOURCE
69414-01OtherHUMANA
OHP00222905OtherRAILROAD MEDICARE
25-20465OtherUNITED
OH0798324Medicare PIN
311438871044OtherCARESOURCE MEDICAID
25-20465OtherUNITED