Provider Demographics
NPI:1588792501
Name:CLARKSON, PETA (MD)
Entity type:Individual
Prefix:DR
First Name:PETA
Middle Name:
Last Name:CLARKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 ASHFORD DR
Mailing Address - Street 2:
Mailing Address - City:CHADDS FORD
Mailing Address - State:PA
Mailing Address - Zip Code:19317-8230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1509
Practice Address - Country:US
Practice Address - Phone:302-655-7110
Practice Address - Fax:302-655-6185
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00075962084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000037785Medicaid