Basic Information
| Provider Information | |||||||||
| NPI: | 1306041173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13000 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336124745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525978287 | ||||||||
| FaxNumber: | 3525977060 | ||||||||
| Practice Location | |||||||||
| Address1: | 13000 BRUCE B. DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525978287 | ||||||||
| FaxNumber: | 3525977060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 06/30/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | PO 3277 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213EP1101X | PO 3277 | FL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65962 | 01 | FL | BLUE CROSS - FLORIDA | OTHER | 340648200 | 05 | FL | MEDICAID |