Provider Demographics
NPI:1275633513
Name:CLARK, MICHAEL J (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 COLEGATE DR BLDG 3
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-9549
Mailing Address - Country:US
Mailing Address - Phone:740-568-4814
Mailing Address - Fax:740-374-3165
Practice Address - Street 1:4411 FISHER RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-9334
Practice Address - Country:US
Practice Address - Phone:740-591-8118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.002676207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0480895Medicaid
OH0480895Medicaid
OH4050626Medicare PIN