Provider Demographics
NPI:1356693386
Name:CLARK, DWIGHT LAMONT
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:LAMONT
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SW 27 AVENUE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135
Mailing Address - Country:US
Mailing Address - Phone:305-668-9000
Mailing Address - Fax:305-662-1788
Practice Address - Street 1:701 SW 27 AVENUE
Practice Address - Street 2:SUITE 500
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135
Practice Address - Country:US
Practice Address - Phone:305-668-9000
Practice Address - Fax:305-662-1788
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator