Provider Demographics
NPI:1760345250
Name:CLARK, RAYMOND THOMAS
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:THOMAS
Last Name:CLARK
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 S INTERNATIONAL PKWY STE 2051
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1414
Mailing Address - Country:US
Mailing Address - Phone:407-284-1191
Mailing Address - Fax:
Practice Address - Street 1:1307 S INTERNATIONAL PKWY STE 2051
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1414
Practice Address - Country:US
Practice Address - Phone:407-284-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-03
Last Update Date:2025-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program