Provider Demographics
NPI:1235166943
Name:CLARK, JOHN D (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746649
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6649
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:1340 S 18TH ST STE 104
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4733
Practice Address - Country:US
Practice Address - Phone:904-277-3311
Practice Address - Fax:904-277-3343
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-238642084N0400X
FLME1692582084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200300630AMedicaid
KSG04308Medicare UPIN
KS103764Medicare ID - Type Unspecified