Provider Demographics
NPI:1609876846
Name:EDWARD C. CLARK,M.D.,P.A.
Entity Type:Organization
Organization Name:EDWARD C. CLARK,M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-843-7711
Mailing Address - Street 1:11355 PEMBROOKE SQ
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4805
Mailing Address - Country:US
Mailing Address - Phone:301-843-7711
Mailing Address - Fax:301-932-9195
Practice Address - Street 1:11355 PEMBROOKE SQ
Practice Address - Street 2:SUITE 107
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4805
Practice Address - Country:US
Practice Address - Phone:301-843-7711
Practice Address - Fax:301-932-9195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0017492207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========OtherTAX ID NUMBER
MD=========OtherTAX ID NUMBER