Individual
FRED CLARKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
20016 HOLLIS AVENUE, JAMAICA, NY 11412
(718) 736-8204
(718) 736-8505
Mailing address
80 MARCUS DR, PROVIDER ENROLLMENT, MELVILLE, NY 11747-4230
(631) 391-7889
(631) 454-4163
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
206376
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01862739
—
NY
Enumeration date
04/22/2006
Last updated
01/18/2013
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