Provider Demographics
NPI:1457895351
Name:CLARK, OMAR-SHAY (DC)
Entity Type:Individual
Prefix:DR
First Name:OMAR-SHAY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2378 SURFSIDE BLVD
Mailing Address - Street 2:SUITE A133
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-3181
Mailing Address - Country:US
Mailing Address - Phone:239-205-3700
Mailing Address - Fax:
Practice Address - Street 1:2378 SURFSIDE BLVD
Practice Address - Street 2:SUITE A133
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-3181
Practice Address - Country:US
Practice Address - Phone:239-205-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11971111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor