MEDICARE: JUSTIN CLARK D.O.

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	207K00000X	Allergy & Immunology Physician	OS9224	FL

General Provider Information

NPI Number	:	1538129085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN CLARK D.O.

Provider Business Mailing Address
First Line	:	362 BEAL PKWY NW STE 105
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-3926
Country	:	US
Telephone Number	:	850-862-3020
Fax Number	:	850-862-1363

Provider Business Practice Location Address
First Line	:	362 BEAL PKWY NW STE 105
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-3926
Country	:	US
Telephone Number	:	850-862-3020
Fax Number	:	850-862-1363

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

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	03/17/2018

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