Individual
GARY L CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA C
Contact information
Practice address
605 LAMAR AVE, BROOKSVILLE, FL 34601-3211
(352) 799-5411
(352) 544-2713
Mailing address
605 LAMAR AVE, BROOKSVILLE, FL 34601-3211
(352) 799-5411
(352) 544-2713
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA2265
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
290338500
—
FL
01
—
900013195
RAILROAD MEDICARE
FL
01
—
970028329
RAILROAD MEDICARE
FL
01
—
970029323
RAILROAD MEDICARE
FL
01
—
Y00ZL
BC/BS FL
FL
Enumeration date
09/01/2005
Last updated
09/22/2014
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