Healthcare Provider Details

I. General information

NPI: 1407235724
Provider Name (Legal Business Name): NICHOLAS CLARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 10/04/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11190 HEALTH PARK BLVD BLDG 2
NAPLES FL
34110-5729
US

IV. Provider business mailing address

11190 HEALTH PARK BLVD BLDG 2
NAPLES FL
34110-5729
US

V. Phone/Fax

Practice location:
  • Phone: 239-624-4200
  • Fax: 239-624-0311
Mailing address:
  • Phone: 239-624-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number60704
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD61156092
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberME166354
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberMD61156092
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: