Provider Demographics
NPI:1174626535
Name:CLARK, DENISE S (DO)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:1118 S ORANGE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1200
Mailing Address - Country:US
Mailing Address - Phone:321-281-8400
Mailing Address - Fax:321-281-8904
Practice Address - Street 1:1118 S ORANGE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1200
Practice Address - Country:US
Practice Address - Phone:321-281-8400
Practice Address - Fax:321-281-8904
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2008-02-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS6040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E71631Medicare UPIN