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General NPI Number Information
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NPI Number | 1609876846
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Entity Type | Organization
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Legal Business Name | EDWARD C. CLARK,M.D.,P.A.
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Dates
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Enumeration Date | 07/29/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 11355 PEMBROOKE SQ SUITE 107
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City | WALDORF
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State | MD
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Zip | 20603-4805
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Country | US
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Telephone | 301-843-7711
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Fax | 301-932-9195
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Provider Business Mailing Address
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Address Line | 11355 PEMBROOKE SQ SUITE 107
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City | WALDORF
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State | MD
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Zip | 20603-4805
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Country | US
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Telephone | 301-843-7711
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Fax | 301-932-9195
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Authorized Official
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Title or Position | OWNER
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Name | EDWARD C CLARK
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Credential | M.D.
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Telephone | 301-843-7711
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | D0017492
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License Number State | MD
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