Provider Demographics
NPI:1922640721
Name:CLARK, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
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 1:2040 GLEASON AVE APT 2K
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-5282
Mailing Address - Country:US
Mailing Address - Phone:646-939-0733
Mailing Address - Fax:
Practice Address - Street 1:160 CONVENT AVE
Practice Address - Street 2:HARRIS HALL H-15
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-9198
Practice Address - Country:US
Practice Address - Phone:212-650-7745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-13
Last Update Date:2019-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program