MEDICARE: DR. VERGENA MONTGOMERY CLARK MD

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	207R00000X	Internal Medicine Physician	ME76527	FL
2	207R00000X	Internal Medicine Physician	56987	GA

General Provider Information

NPI Number	:	1326527144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VERGENA MONTGOMERY CLARK MD

Provider Business Mailing Address
First Line	:	6101 BLUE LAGOON DR STE 200
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-3168
Country	:	US
Telephone Number	:	404-441-1365
Fax Number	:	210-428-6384

Provider Business Practice Location Address
First Line	:	3142 ESPLANADE CIR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-4221
Country	:	US
Telephone Number	:	404-441-1365
Fax Number	:	210-428-6384

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

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	08/26/2022

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