Basic Information
| Provider Information | |||||||||
| NPI: | 1659397578 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARKSON | ||||||||
| FirstName: | EARL | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 BROADWAY DEPARTMENT OF MANAGED CARE ROOM 2B230 | ||||||||
| Address2: | WOODHULL MEDICAL & MENTAL HEALTH CENTER | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638000 | ||||||||
| FaxNumber: | 7186303122 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 BROADWAY | ||||||||
| Address2: | WOODHULL MEDICAL & MENTAL HEALTH CENTER | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638000 | ||||||||
| FaxNumber: | 7182506431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 09/17/2014 | ||||||||
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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 | 1223S0112X | 036255 | NY | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00759251 | 05 | NY | MEDICAID | 4572181 | 01 | NY | AETNA | OTHER | P417983 | 01 | NY | OXFORD | OTHER |