Provider Demographics
NPI:1528121753
Name:CLARKE, MATTHEW ALAN THEOPHILUS (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ALAN THEOPHILUS
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:12131 234TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-1026
Mailing Address - Country:US
Mailing Address - Phone:718-723-6416
Mailing Address - Fax:718-949-9874
Practice Address - Street 1:3051 36TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4704
Practice Address - Country:US
Practice Address - Phone:718-626-4444
Practice Address - Fax:718-949-9874
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY209612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG97635Medicare UPIN