1194862730 NPI number — DR. JOHN F.J. CLARK III

Table of content: CATHERINE CONNOLLY APRN.CNP (NPI 1679244651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194862730 NPI number — DR. JOHN F.J. CLARK III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
JOHN
Provider Middle Name:
F.J.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
JOHN
Provider Other Middle Name:
FRANCIS, JAMES
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
III
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1194862730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 CENTRAL PARK W
Provider Second Line Business Mailing Address:
SUITE # 3
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10024-4101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-769-0666
Provider Business Mailing Address Fax Number:
212-799-6193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 CENTRAL PARK W
Provider Second Line Business Practice Location Address:
SUITE # 3
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10024-4101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-769-0666
Provider Business Practice Location Address Fax Number:
212-799-6193
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  160560-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00963231 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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