Provider Demographics
NPI:1114988540
Name:CLARK, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2125
Mailing Address - Country:US
Mailing Address - Phone:937-283-9815
Mailing Address - Fax:937-283-9839
Practice Address - Street 1:596 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2123
Practice Address - Country:US
Practice Address - Phone:937-283-2588
Practice Address - Fax:937-283-2594
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062520C207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0969420Medicaid
F80931Medicare UPIN
OHH100130Medicare PIN
OH0969420Medicaid
OH0969420Medicaid