Provider Demographics
NPI:1972947059
Name:CLARKE, CHRISTINA ELENA (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ELENA
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:ELENA
Other - Last Name:PORTAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:108 HARBOURSIDE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-8004
Mailing Address - Country:US
Mailing Address - Phone:757-810-2735
Mailing Address - Fax:
Practice Address - Street 1:930 REVOLUTION ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3718
Practice Address - Country:US
Practice Address - Phone:443-351-3376
Practice Address - Fax:410-939-7832
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036143350207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty