Basic Information
| Provider Information | |||||||||
| NPI: | 1174557896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKSON | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | OAKHURST MEDICAL CLINIC | ||||||||
| Address2: | 130 20 PARK BLVD | ||||||||
| City: | SEMINOLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273933404 | ||||||||
| FaxNumber: | 7273934814 | ||||||||
| Practice Location | |||||||||
| Address1: | OAKHURST MEDICAL CLINIC | ||||||||
| Address2: | 130 20 PARK BLVD | ||||||||
| City: | SEMINOLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273933404 | ||||||||
| FaxNumber: | 7273934814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OS0002968 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 2361160 | 01 | AETNA | OTHER | 284247 | 01 | AVMED | OTHER |