Provider Demographics
NPI:1811092752
Name:CLARKE, CAROL BILISTON (MD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:BILISTON
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 WEBB RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-3241
Mailing Address - Country:US
Mailing Address - Phone:813-329-6012
Mailing Address - Fax:813-884-9295
Practice Address - Street 1:6001 WEBB RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-3241
Practice Address - Country:US
Practice Address - Phone:813-329-6012
Practice Address - Fax:813-884-9295
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL50290207P00000X
NY161843207P00000X
TNMD0000016088207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02808542Medicaid
NY204488426OtherBLUE SHIELD
FL045598900Medicaid
TN1521618Medicaid
VA1811092752Medicaid
NYRB3661Medicare PIN
NY02808542Medicaid
NY204488426OtherBLUE SHIELD
TN103I080012Medicare PIN
FLD68985Medicare UPIN