1912059494 NPI number — DR. GRETA FIELDS CLARKE MD

Table of content: DR. GRETA FIELDS CLARKE MD (NPI 1912059494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912059494 NPI number — DR. GRETA FIELDS CLARKE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARKE
Provider First Name:
GRETA
Provider Middle Name:
FIELDS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIMS
Provider Other First Name:
GRETA
Provider Other Middle Name:
CLARKE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1912059494
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5758 GEARY BLVD
Provider Second Line Business Mailing Address:
#534
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94121-2112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-418-4098
Provider Business Mailing Address Fax Number:
415-221-5078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5758 GEARY BLVD
Provider Second Line Business Practice Location Address:
#534
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94121-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-418-4098
Provider Business Practice Location Address Fax Number:
415-221-5078
Provider Enumeration Date:
01/17/2007

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: 207N00000X , with the licence number:  G33757 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00G337570 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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