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General NPI Number Information
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NPI Number | 1235166943
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Entity Type | Individual
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Provider Name | JOHN D CLARK M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/27/2006
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Last Update Date | 08/02/2024
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Provider Practice Location Address
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Address Line | 1340 S 18TH ST STE 104
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City | FERNANDINA BEACH
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State | FL
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Zip | 32034-4733
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Country | US
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Telephone | 904-277-3311
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Fax | 904-277-3343
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Provider Business Mailing Address
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Address Line | PO BOX 746649
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City | ATLANTA
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State | GA
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Zip | 30374-6649
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Country | US
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Telephone | 904-202-2092
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Fax | 904-376-4075
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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 | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 04-23864
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | ME169258
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License Number State | FL
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