Basic Information
| Provider Information | |||||||||
| NPI: | 1508056441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | DEDRIC | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 PRYTANIA ST STE 35 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701153678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048978412 | ||||||||
| FaxNumber: | 5042495311 | ||||||||
| Practice Location | |||||||||
| Address1: | 3715 PRYTANIA ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701153768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048978276 | ||||||||
| FaxNumber: | 5048978336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 200764 | LA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207RC0001X | MD.200764 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 1066885 | 05 | LA | MEDICAID |