Provider Demographics
NPI:1427033463
Name:CLARK, ELIZABETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:12469 EMERALD COAST PKWY W
Mailing Address - Street 2:STE 101
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-8305
Mailing Address - Country:US
Mailing Address - Phone:850-654-3376
Mailing Address - Fax:850-654-3320
Practice Address - Street 1:4400 E HIGHWAY 20
Practice Address - Street 2:STE 410
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8779
Practice Address - Country:US
Practice Address - Phone:850-654-3376
Practice Address - Fax:850-654-3320
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2013-01-15
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Provider Licenses
StateLicense IDTaxonomies
FLME66298207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252552600Medicaid
FL41899Medicare PIN
G57270Medicare UPIN