Provider Demographics
NPI:1174557896
Name:CLARKSON, FREDERICK WESLEY (DO)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:WESLEY
Last Name:CLARKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:OAKHURST MEDICAL CLINIC
Mailing Address - Street 2:130 20 PARK BLVD
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33776
Mailing Address - Country:US
Mailing Address - Phone:727-393-3404
Mailing Address - Fax:727-393-4814
Practice Address - Street 1:OAKHURST MEDICAL CLINIC
Practice Address - Street 2:130 20 PARK BLVD
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776
Practice Address - Country:US
Practice Address - Phone:727-393-3404
Practice Address - Fax:727-393-4814
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0002968208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
2361160OtherAETNA
284247OtherAVMED
81726ZMedicare ID - Type Unspecified
284247OtherAVMED