Provider Demographics
NPI:1316046816
Name:CLARK, EDMUND JUSTIN (MD)
Entity type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:JUSTIN
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:109 W 27TH ST RM 5S
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6208
Mailing Address - Country:US
Mailing Address - Phone:833-351-8255
Mailing Address - Fax:
Practice Address - Street 1:101 N. MONROE STREET
Practice Address - Street 2:SUITE 800 (PRIVATE OFFICE 860)
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-1500
Practice Address - Country:US
Practice Address - Phone:833-351-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1053442084P0800X
TN750232084P0800X
NY3395522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry