Provider Demographics
NPI:1124125505
Name:CLARK, STEVEN LESTER (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:LESTER
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-897-3200
Mailing Address - Fax:850-897-2353
Practice Address - Street 1:4586 E HIGHWAY 20
Practice Address - Street 2:SUITE B
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-9724
Practice Address - Country:US
Practice Address - Phone:850-897-3200
Practice Address - Fax:850-897-2353
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002577400Medicaid