Healthcare Provider Details

I. General information

NPI: 1659951358
Provider Name (Legal Business Name): ELISE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 S DOUGLAS RD
CORAL GABLES FL
33134-6923
US

IV. Provider business mailing address

20900 BISCAYNE BLVD
AVENTURA FL
33180-1407
US

V. Phone/Fax

Practice location:
  • Phone: 305-445-8461
  • Fax:
Mailing address:
  • Phone: 305-682-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS20920
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: