Provider Demographics
NPI:1356304786
Name:CLARK, JAMES MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
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:PO BOX 595
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-0595
Mailing Address - Country:US
Mailing Address - Phone:270-885-3414
Mailing Address - Fax:270-885-7631
Practice Address - Street 1:215 W 17TH ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1911
Practice Address - Country:US
Practice Address - Phone:270-885-3414
Practice Address - Fax:270-885-7631
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY311862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64311863Medicaid
G97191Medicare UPIN
KY64311863Medicaid