Provider Demographics
NPI:1891920682
Name:CLARK, CHARLOTTE M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:MARIA-CARLOTTA
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:228 E ROUTE 59 # 408
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2905
Mailing Address - Country:US
Mailing Address - Phone:718-362-1411
Mailing Address - Fax:718-414-1651
Practice Address - Street 1:400 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-3206
Practice Address - Country:US
Practice Address - Phone:718-362-1411
Practice Address - Fax:718-414-1651
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-21
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
NY286912207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty