Provider Demographics
NPI:1669471744
Name:CLACK, WILLIAM PEARSON (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:PEARSON
Last Name:CLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:W
Other - Middle Name:PEARSON
Other - Last Name:CLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2001 WEBBER ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-5288
Mailing Address - Country:US
Mailing Address - Phone:941-362-8900
Mailing Address - Fax:941-362-8987
Practice Address - Street 1:2001 WEBBER ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5288
Practice Address - Country:US
Practice Address - Phone:941-362-8900
Practice Address - Fax:941-362-8987
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME15752207ZF0201X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372519700Medicaid
FL372519700Medicaid