Provider Demographics
NPI:1629278882
Name:LOWELL F. CLARK MD PA
Entity Type:Organization
Organization Name:LOWELL F. CLARK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:FOLK
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:352-787-1600
Mailing Address - Street 1:212 S FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-6703
Mailing Address - Country:US
Mailing Address - Phone:352-787-1600
Mailing Address - Fax:352-793-3282
Practice Address - Street 1:212 S FLORIDA ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-6703
Practice Address - Country:US
Practice Address - Phone:352-787-1600
Practice Address - Fax:352-793-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45090207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33972OtherBCBS OF FLORIDA GROUP ID
FL33972AMedicare PIN
FL33972Medicare PIN