Provider Demographics
NPI:1891219614
Name:CLIFFORD P CLARK MD P A
Entity Type:Organization
Organization Name:CLIFFORD P CLARK MD P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:407-629-5555
Mailing Address - Street 1:701 W MORSE BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 W MORSE BLVD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3749
Practice Address - Country:US
Practice Address - Phone:407-629-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty