Provider Demographics
NPI:1790774719
Name:CLARK, JANET E (MD)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3249 SUNSET KEY CIR
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33955-1969
Mailing Address - Country:US
Mailing Address - Phone:941-575-9372
Mailing Address - Fax:
Practice Address - Street 1:3249 SUNSET KEY CIR
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33955-1969
Practice Address - Country:US
Practice Address - Phone:941-575-9372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067790207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260754900Medicaid
FL2488479OtherAETNA
FL050079777OtherMCRR
FL51855ZOtherMCR
FL0867335OtherCIGNA
FL51855OtherBSFL
FL260754900Medicaid
FL260754900Medicaid