Provider Demographics
NPI:1962456426
Name:WIRTA-CLARKE, YVETTE (DO)
Entity Type:Individual
Prefix:
First Name:YVETTE
Middle Name:
Last Name:WIRTA-CLARKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:YVETTE
Other - Middle Name:
Other - Last Name:WIRTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:100 SW ATLANTA AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7521
Practice Address - Country:US
Practice Address - Phone:772-398-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8390207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05149OtherBCBS
FL05149OtherBCBS
FL05149BMedicare ID - Type Unspecified