Provider Demographics
NPI:1336103563
Name:CLARK, LOWELL F (MD)
Entity Type:Individual
Prefix:
First Name:LOWELL
Middle Name:F
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 1:212 S FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-6703
Mailing Address - Country:US
Mailing Address - Phone:352-793-2441
Mailing Address - Fax:352-793-3282
Practice Address - Street 1:212 S FLORIDA ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-6703
Practice Address - Country:US
Practice Address - Phone:352-793-2441
Practice Address - Fax:352-793-3282
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045090207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35207OtherBCBS PROVIDER ID
FL35207XMedicare PIN
FL35207UMedicare PIN
FLD85634Medicare UPIN