Provider Demographics
NPI:1912059494
Name:CLARKE, GRETA FIELDS (MD)
Entity Type:Individual
Prefix:DR
First Name:GRETA
Middle Name:FIELDS
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:GRETA
Other - Middle Name:CLARKE
Other - Last Name:WIMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5758 GEARY BLVD
Mailing Address - Street 2:#534
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-2112
Mailing Address - Country:US
Mailing Address - Phone:415-418-4098
Mailing Address - Fax:415-221-5078
Practice Address - Street 1:5758 GEARY BLVD
Practice Address - Street 2:#534
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-2112
Practice Address - Country:US
Practice Address - Phone:415-418-4098
Practice Address - Fax:415-221-5078
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33757207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G337570Medicaid
CA00G337570Medicaid
A45669Medicare UPIN