Provider Demographics
NPI:1376751917
Name:CLARK, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25106 CORN FIELD CT
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-8562
Mailing Address - Country:US
Mailing Address - Phone:951-679-3324
Mailing Address - Fax:
Practice Address - Street 1:140 SYLVESTER RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-3521
Practice Address - Country:US
Practice Address - Phone:619-553-8719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman