Provider Demographics
NPI:1023110418
Name:CLARKE, JOHN MITCHELL (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MITCHELL
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1615 PASADENA AVE S
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4516
Mailing Address - Country:US
Mailing Address - Phone:727-345-2929
Mailing Address - Fax:727-345-0340
Practice Address - Street 1:1615 PASADENA AVE S
Practice Address - Street 2:SUITE 330
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4516
Practice Address - Country:US
Practice Address - Phone:727-345-2929
Practice Address - Fax:727-345-0340
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0012246208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040195100Medicaid
FL040195100Medicaid
FLPTAN52752XMedicare PIN