Provider Demographics
NPI:1851326219
Name:CLARK, JAMES ELLIOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ELLIOTT
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 OSCEOLA ST
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-7857
Mailing Address - Country:US
Mailing Address - Phone:407-339-9500
Mailing Address - Fax:407-339-2266
Practice Address - Street 1:475 OSCEOLA ST
Practice Address - Street 2:SUITE 1200
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-7857
Practice Address - Country:US
Practice Address - Phone:407-339-9500
Practice Address - Fax:407-339-2266
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 35769174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045664100Medicaid
FL2153489OtherAETNA PROVIDER ID#
FL07-00018OtherUHC PROVIDER ID#
FL47361OtherBC/BS PROVIDER ID#
FL592438966OtherTAX IDENTIFICATION NUMBER
FL2153489OtherAETNA PROVIDER ID#
FL07-00018OtherUHC PROVIDER ID#
FL47361Medicare PIN