Provider Demographics
NPI:1093712556
Name:CLARK, JAMES G (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:G
Last Name:CLARK
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 1:315 ISLE OF CAPRI DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2409
Mailing Address - Country:US
Mailing Address - Phone:954-319-0225
Mailing Address - Fax:
Practice Address - Street 1:315 ISLE OF CAPRI DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2409
Practice Address - Country:US
Practice Address - Phone:954-319-0225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0077207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12232033Medicaid
N/AMedicare PIN