Desra Kay Clark, D.O.

Primary specialty

Adult Medicine PhysicianTaxonomy code 207QA0505X

License

OS12364 Issued in FL

Practice address

7227 N US Highway 1
Cocoa, FL 32927-5020

Phone

(321) 877-2740

Fax

(321) 877-2793

NPI assigned

Jun 22, 2012

Last updated

Jul 21, 2022By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Ms. Desra Kay Kiely Former name

Medicare fee-for-service enrollment

Enrolled in FL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1340323200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1658361600000",
    "number": "1477816601",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1137",
            "city": "MELBOURNE",
            "state": "FL",
            "postal_code": "329021137",
            "telephone_number": "321-952-9696",
            "fax_number": "321-952-7937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7227 N US HIGHWAY 1",
            "city": "COCOA",
            "state": "FL",
            "postal_code": "329275020",
            "telephone_number": "321-877-2740",
            "fax_number": "321-877-2793"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "DESRA",
        "middle_name": "KAY",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-06-22",
        "last_updated": "2022-07-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207QA0505X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Adult Medicine",
            "state": "FL",
            "license": "OS12364",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "019789000",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "DESRA",
            "last_name": "KIELY",
            "middle_name": "KAY",
            "prefix": "MS.",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Chloe's Place I
• Eejong Choi, PHARMD
• Elaine Christmas, LMHC
• Claire C Boland Counseling and Consulting,Inc.
• Carol Denise Clark, LMHC
• Bethany Renae Clarke
• Capen Shayne Clarke
• James W Clement
• Jermaine Clentscale
• Stephanie Clover

• Adult Medicine Physician in Cocoa, FL
• Providers in Cocoa, FL by specialty
• Adult Medicine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.