Provider Demographics
NPI:1831226604
Name:CLARK, TIMOTHY DALE (CCP)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DALE
Last Name:CLARK
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9335 SW 35TH LN
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-8620
Mailing Address - Country:US
Mailing Address - Phone:352-665-1209
Mailing Address - Fax:352-332-3761
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:SUITE NG-28
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-665-1209
Practice Address - Fax:352-332-3761
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1312783332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5627130001Medicare NSC