Provider Demographics
NPI:1649256199
Name:CLARKE, RONALD J (DO)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:CLARKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6950 WILLIAMS ROAD
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14304
Mailing Address - Country:US
Mailing Address - Phone:716-297-1027
Mailing Address - Fax:716-298-4081
Practice Address - Street 1:6950 WILLIAMS ROAD
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304
Practice Address - Country:US
Practice Address - Phone:716-297-1027
Practice Address - Fax:716-298-4081
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00892360Medicaid
B35600Medicare UPIN
NY13061BMedicare ID - Type Unspecified