Provider Demographics
NPI:1891197141
Name:CLARK, MARVIN
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 E TREMONT AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-4301
Mailing Address - Country:US
Mailing Address - Phone:646-399-3668
Mailing Address - Fax:
Practice Address - Street 1:1034 E 233RD ST STE 2
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-3317
Practice Address - Country:US
Practice Address - Phone:347-913-4373
Practice Address - Fax:914-462-4513
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency