Healthcare Provider Details

I. General information

NPI: 1194796128
Provider Name (Legal Business Name): PERRIN C CLARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W GRANADA BLVD SUITE 4
ORMOND BEACH FL
32174-8154
US

IV. Provider business mailing address

15280 NW 79TH CT STE 200
MIAMI LAKES FL
33016-5873
US

V. Phone/Fax

Practice location:
  • Phone: 386-677-8808
  • Fax: 386-677-9919
Mailing address:
  • Phone: 305-558-3732
  • Fax: 786-907-4485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberN2444
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: