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General NPI Number Information
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NPI Number | 1275470171
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Entity Type | Individual
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Provider Name | AMANDA DE CASTRO CLARK MD
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Gender | Female
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Dates
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Enumeration Date | 04/30/2026
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Last Update Date | 04/30/2026
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Provider Practice Location Address
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Address Line | 1120 15TH ST
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City | AUGUSTA
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State | GA
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Zip | 30912-0004
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Country | US
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Telephone | 706-721-0211
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Fax |
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Provider Business Mailing Address
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Address Line | 470 LAKE SHORE PKWY
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City | DAVENPORT
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State | FL
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Zip | 33896-7861
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Country | US
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Telephone | 863-282-0652
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Fax |
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 112659
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License Number State | GA
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