Provider Demographics
NPI:1558105437
Name:CLARK, CAMERON (DPT, ATC)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12353 NW 25TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33323-1724
Mailing Address - Country:US
Mailing Address - Phone:315-591-5412
Mailing Address - Fax:
Practice Address - Street 1:6290 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1917
Practice Address - Country:US
Practice Address - Phone:954-302-8746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTT41802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist