Provider Demographics
NPI:1063683597
Name:CLARK, MICHAEL DWAYNE
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DWAYNE
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 1:619 CLARENCE ST APT 5
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5370
Mailing Address - Country:US
Mailing Address - Phone:337-721-8070
Mailing Address - Fax:337-721-8060
Practice Address - Street 1:619 CLARENCE ST APT 5
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5370
Practice Address - Country:US
Practice Address - Phone:337-721-8070
Practice Address - Fax:337-721-8060
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver