MEDICARE: MR. MATTHEW WILLIAM CLARK IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1245284629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW WILLIAM CLARK IDC

Provider Business Mailing Address
First Line	:	453 CODY DR
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4214
Country	:	US
Telephone Number	:	904-270-5936
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS PHILIPPINE SEA
Second Line	:
City	:	FPO
State	:	AA
Zip	:	34092-1178
Country	:	US
Telephone Number	:	904-270-6502
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	05/12/2010

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