Provider Demographics
NPI:1639189905
Name:HABER, CLARK D (MD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:D
Last Name:HABER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 BEACH CHANNEL DR
Mailing Address - Street 2:PENINSULA HOSPITAL CENTER
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1042
Mailing Address - Country:US
Mailing Address - Phone:718-734-2700
Mailing Address - Fax:
Practice Address - Street 1:5115 BEACH CHANNEL DR
Practice Address - Street 2:PENINSULA HOSPITAL CENTER
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1042
Practice Address - Country:US
Practice Address - Phone:718-734-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129871207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01427292Medicaid
F70756Medicare UPIN
NY01427292Medicaid