| Doctor Name: | CLARK CHEN |
| NPI Number: | 1457733719 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | UO4679 |
| Business Practice Address: | 379 6th Ave W Bradenton, FL - 342058820 |
| Business Phone Number: | 9417824100 |
| Business Fax Number: | 9417824101 |
| Mailing Address: | Po Box 9478, BRADENTON |
| State: | FL |
| Postal Code: | 342069478 |
| Phone Number: | 9417824299 |
| Fax Number: | 9417824301 |
| NPI Enumeration Date: | 06/23/2015 |
| NPI Last Update Date: | 06/23/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | UO4679 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |