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 1:1535 ALEXANDRIA PL N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-4049
Mailing Address - Country:US
Mailing Address - Phone:352-215-4391
Mailing Address - Fax:
Practice Address - Street 1:550 FOOTHILL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1106
Practice Address - Country:US
Practice Address - Phone:352-215-4391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1053442084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry