Provider Demographics
NPI:1174610570
Name:CLARK, JOHN ELLIOTT (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELLIOTT
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:50 IRVING ST NW
Mailing Address - Street 2:STE 412
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20422-0001
Mailing Address - Country:US
Mailing Address - Phone:202-507-9952
Mailing Address - Fax:202-836-6921
Practice Address - Street 1:50 IRVING ST NW
Practice Address - Street 2:STE 412
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20422-0001
Practice Address - Country:US
Practice Address - Phone:202-507-9952
Practice Address - Fax:202-836-6921
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DCMD14155208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC7666OtherCAREFIRST
DC00247377Medicaid
DC7666OtherCAREFIRST
DC00247377Medicaid