Basic Information
Provider Information | |||||||||
NPI: | 1871267195 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOWELL F CLARK MD PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 212 S FLA ST | ||||||||
Address2: |   | ||||||||
City: | BUSHNELL | ||||||||
State: | FL | ||||||||
PostalCode: | 335136703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527932441 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 910 W MYERS BLVD | ||||||||
Address2: |   | ||||||||
City: | MASCOTTE | ||||||||
State: | FL | ||||||||
PostalCode: | 347539748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3525578700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2021 | ||||||||
LastUpdateDate: | 08/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLARK | ||||||||
AuthorizedOfficialFirstName: | LOWELL | ||||||||
AuthorizedOfficialMiddleName: | F. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3527932441 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.