Provider Demographics
NPI:1073621215
Name:CLARK, EILIS (MD)
Entity Type:Individual
Prefix:DR
First Name:EILIS
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S SALISBURY TER
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-5104
Mailing Address - Country:US
Mailing Address - Phone:352-631-7460
Mailing Address - Fax:352-600-0549
Practice Address - Street 1:210 S SALISBURY TER
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-5104
Practice Address - Country:US
Practice Address - Phone:352-631-7460
Practice Address - Fax:863-210-2927
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME800412084P0800X, 207Q00000X, 2084P0800X
NC96011642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine