Basic Information
| Provider Information | |||||||||
| NPI: | 1932260551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARE | ||||||||
| FirstName: | EVERTON | ||||||||
| MiddleName: | GEORGE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD | ||||||||
| Address2: | FL 2 | ||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 ROE AVE | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149051629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077377770 | ||||||||
| FaxNumber: | 6072713686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 09/11/2017 | ||||||||
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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 | 207R00000X | MD429147 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 048921 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 232349 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03502967 | 05 | NY | MEDICAID | 1018327020001 | 05 | PA | MEDICAID |