MEDICARE: CAMERON CLARK DPT, ATC

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	225100000X	Physical Therapist	PTT41802	FL

General Provider Information

NPI Number	:	1558105437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMERON CLARK DPT, ATC

Provider Business Mailing Address
First Line	:	12353 NW 25TH ST
Second Line	:
City	:	PLANTATION
State	:	FL
Zip	:	33323-1724
Country	:	US
Telephone Number	:	315-591-5412
Fax Number	:

Provider Business Practice Location Address
First Line	:	6290 N FEDERAL HWY
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-1917
Country	:	US
Telephone Number	:	954-302-8746
Fax Number	:

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

Provider Enumeration Date	:	06/24/2024
Last Update Date	:	04/30/2025

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