Provider Demographics
NPI:1295760908
Name:CLARK, MAIYA YETUNDE ELON (MD)
Entity type:Individual
Prefix:DR
First Name:MAIYA
Middle Name:YETUNDE ELON
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 KEARNEY ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2959
Mailing Address - Country:US
Mailing Address - Phone:202-832-8152
Mailing Address - Fax:
Practice Address - Street 1:344 UNIVERSITY BLVD W
Practice Address - Street 2:SUITE 325
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-1948
Practice Address - Country:US
Practice Address - Phone:301-593-5440
Practice Address - Fax:301-593-5501
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061964208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406773800Medicaid
MDI28087Medicare UPIN