Individual
CLINTON EDWARD CLARKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1300 N 12TH ST, SUITE 605, PHOENIX, AZ 85006-2848
(602) 839-2668
(602) 839-2067
Mailing address
1300 N 12TH ST, SUITE 605, PHOENIX, AZ 85006-2848
(602) 839-2668
(602) 839-2067
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
33324
AZ
207QS0010X
Sports Medicine (Family Medicine) Physician
33324
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00616915
RAILROAD MEDICARE
AZ
01
—
P00745791
RAILROAD MEDICARE 8/1/09
AZ
01
—
Z145980
MEDICARE PTAN
AZ
Enumeration date
06/26/2006
Last updated
11/10/2011
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