Basic Information
| Provider Information | |||||||||
| NPI: | 1477555845 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 39179 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850699179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950718 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 E PALM LN | ||||||||
| Address2: | SUITE A260 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850044603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022541136 | ||||||||
| FaxNumber: | 6022791720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 09/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 32231 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 859142 | 05 | AZ | MEDICAID | AZ0756690 | 01 | AZ | BLUE CROSS BLUE SHIELD | OTHER |