Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RR0500X | Rheumatology | OS8284 | FL |
NPI | 1073563847 |
---|---|
Provider Name | Jack Clark |
First Address | Fort Myers, FL 33901-9342 |
Second Address | Cape Coral, FL 33990-3798 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2006 |
Last Update Date | 29/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
272380800 | (05) | FL |
G63437 | (02) | FL |