Provider Demographics
NPI:1598779100
Name:CLARK, LISA BARDY (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:BARDY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12815 HIGHWAY 98 WEST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32550
Mailing Address - Country:US
Mailing Address - Phone:850-269-0111
Mailing Address - Fax:850-269-0114
Practice Address - Street 1:12815 HIGHWAY 98 WEST
Practice Address - Street 2:SUITE 116
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550
Practice Address - Country:US
Practice Address - Phone:850-269-0111
Practice Address - Fax:850-269-0114
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME73997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7589056OtherAETNA USHC #
FL43826OtherBCBS OF FL PROVIDER #
FL43826OtherBCBS OF FL PROVIDER #