Provider Demographics
NPI:1275596041
Name:CLARK, MICHAEL T (D C)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:CLARK
Suffix:
Gender:M
Credentials:D C
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:T
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:23 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03867-2926
Mailing Address - Country:US
Mailing Address - Phone:603-332-8989
Mailing Address - Fax:603-332-8989
Practice Address - Street 1:23 CHARLES ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03867-2926
Practice Address - Country:US
Practice Address - Phone:603-332-8989
Practice Address - Fax:603-332-8989
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11809510184A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH19394OtherMATTHEW THORNTON HEALTH P
NJ7802 OUT OF STATEOtherANTHEM NJ
NH80705OtherGREAT WEST HC
NHAA44982OtherHPHC
63665OtherGREAT WEST NA
NH0508438Y0NH01OtherANTHEM
NH453731OtherAETNA
NH30001768Medicaid
NH3228OtherCIGNA
NHAA44982OtherHPHC
NH453731OtherAETNA