Provider Demographics
NPI:1609022086
Name:CLARK, FRED ELTON III (MD)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:ELTON
Last Name:CLARK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4401 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-4728
Mailing Address - Country:US
Mailing Address - Phone:727-525-4401
Mailing Address - Fax:727-525-7788
Practice Address - Street 1:4401 4TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-4728
Practice Address - Country:US
Practice Address - Phone:727-525-4401
Practice Address - Fax:727-525-7788
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME102187207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL137000Medicaid
FL7A6EUOtherBCBS
FLCF695WMedicare UPIN