Provider Demographics
NPI:1407845878
Name:CLARKE, EDWARD HOLTON (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:HOLTON
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 1:722 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-2435
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2099
Practice Address - Street 1:147 W GRAY ST
Practice Address - Street 2:MARK TWAIN BUILDING
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3017
Practice Address - Country:US
Practice Address - Phone:607-733-6698
Practice Address - Fax:607-733-6762
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1039991208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0685823Medicaid
PA0006323570001Medicaid
PA0006323570001Medicaid
NYC59085Medicare UPIN
NY0685823Medicaid