Provider Demographics
NPI:1972676989
Name:CLARKE, JOHN RUSHFORD
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUSHFORD
Last Name:CLARKE
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 1:5181 NE 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3712
Mailing Address - Country:US
Mailing Address - Phone:954-772-1305
Mailing Address - Fax:954-772-2569
Practice Address - Street 1:817 S UNIVERSITY DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3309
Practice Address - Country:US
Practice Address - Phone:954-562-9610
Practice Address - Fax:954-772-2569
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN42721223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT95137Medicare UPIN