Healthcare Provider Details

I. General information

NPI: 1891219614
Provider Name (Legal Business Name): CLIFFORD P CLARK MD P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 08/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W MORSE BLVD
WINTER PARK FL
32789-3749
US

IV. Provider business mailing address

701 W MORSE BLVD
WINTER PARK FL
32789-3749
US

V. Phone/Fax

Practice location:
  • Phone: 407-629-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CLIFFORD CLARK III
Title or Position: OWNER
Credential: MD
Phone: 407-629-5555