Provider Demographics
NPI:1023213642
Name:WALTERS, CLARK (DC)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9375 US HIGHWAY NORTH 19 SUITE A
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-5420
Mailing Address - Country:US
Mailing Address - Phone:727-323-4507
Mailing Address - Fax:727-323-1697
Practice Address - Street 1:9375 US HIGHWAY NORTH 19 SUITE A
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782
Practice Address - Country:US
Practice Address - Phone:727-323-4507
Practice Address - Fax:727-323-1697
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5190111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDF194YMedicare PIN