Provider Demographics
NPI:1285606574
Name:CLARK, STACEY ANN (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 MEDICAL PARK BLVD
Mailing Address - Street 2:#402
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414
Mailing Address - Country:US
Mailing Address - Phone:561-790-2600
Mailing Address - Fax:561-790-1535
Practice Address - Street 1:1447 MEDICAL PARK BLVD
Practice Address - Street 2:#402
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-790-2600
Practice Address - Fax:561-790-1535
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070966208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47177100Medicaid
FL47177100Medicaid