Provider Demographics
NPI:1124028311
Name:CLARK, EDWARD C (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11355 PEMBROOKE SQ
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4805
Mailing Address - Country:US
Mailing Address - Phone:301-843-7711
Mailing Address - Fax:301-932-9195
Practice Address - Street 1:11355 PEMBROOKE SQ
Practice Address - Street 2:SUITE 107
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4805
Practice Address - Country:US
Practice Address - Phone:301-843-7711
Practice Address - Fax:301-932-9195
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2016-08-08
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Provider Licenses
StateLicense IDTaxonomies
MDD0017492207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD228502900Medicaid
MDD66454Medicare UPIN
MD228502900Medicaid