Provider Demographics
NPI:1336113497
Name:CLARK, GABRIEL M (MPT)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13020 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0925
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:813-558-6187
Practice Address - Street 1:909 N DALE MABRY HWY
Practice Address - Street 2:SUITE 300
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1251
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6187
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT011347225100000X
OHOT 5940225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH225100000XOtherTAXONOMY CODE
FLIG332ZMedicare PIN
OHCL4126476Medicare ID - Type Unspecified