Provider Demographics
NPI:1194199919
Name:CLARK FAMILY MEDICINE
Entity Type:Organization
Organization Name:CLARK FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:BARDY
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-269-0111
Mailing Address - Street 1:12815 US HIGHWAY 98 W STE 116
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-3245
Mailing Address - Country:US
Mailing Address - Phone:850-269-0111
Mailing Address - Fax:850-269-0114
Practice Address - Street 1:12815 US HIGHWAY 98 W STE 116
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-3245
Practice Address - Country:US
Practice Address - Phone:850-269-0111
Practice Address - Fax:850-269-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073997261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG77346Medicare UPIN