Provider Demographics
NPI:1407143381
Name:CLARK, MICHAEL JEFFERY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEFFERY
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 1:5671 PEACHTREE DUNWOODY RD.
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-847-9999
Mailing Address - Fax:
Practice Address - Street 1:5671 PEACHTREE DUNWOODY STE 700
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5047
Practice Address - Country:US
Practice Address - Phone:404-847-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4879207X00000X
GA069783207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery