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General NPI Number Information
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NPI Number | 1073621215
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Entity Type | Individual
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Provider Name | EILIS CLARK MD
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Gender | Female
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Dates
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Enumeration Date | 08/28/2006
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Last Update Date | 03/20/2025
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Provider Practice Location Address
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Address Line | 2066 NC-125
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City | ROANOKE RAPIDS
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State | NC
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Zip | 27870
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Country | US
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Telephone | 252-536-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 210 S SALISBURY TER
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City | LECANTO
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State | FL
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Zip | 34461-5104
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Country | US
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Telephone | 352-631-7460
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Fax | 352-600-0549
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME80041
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | ME80041
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 9601164
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License Number State | NC
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