Provider Demographics
NPI:1376579482
Name:CLARK, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
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:
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Mailing Address - Street 1:2007 SCOTTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1638
Mailing Address - Country:US
Mailing Address - Phone:419-334-6624
Mailing Address - Fax:419-334-6602
Practice Address - Street 1:715 S TAFT AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3200
Practice Address - Country:US
Practice Address - Phone:419-334-6624
Practice Address - Fax:419-334-6602
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040176207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0324929Medicaid
OHA26361Medicare UPIN
OH0324929Medicaid