Provider Demographics
NPI:1164551545
Name:CLARK, MICHELLE OLIVETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:OLIVETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4100 REDWOOD RD STE 20A-522
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-2363
Mailing Address - Country:US
Mailing Address - Phone:510-842-8960
Mailing Address - Fax:105-842-8983
Practice Address - Street 1:1005 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1148
Practice Address - Country:US
Practice Address - Phone:415-474-7310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 316652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA 31665OtherSTATE MEDICAL LICENSE
CAA 26565Medicare UPIN
CA00A316650Medicare PIN