Provider Demographics
NPI:1407958291
Name:CLARK, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:7477 S STATE RD
Mailing Address - Street 2:
Mailing Address - City:GOODRICH
Mailing Address - State:MI
Mailing Address - Zip Code:48438-8745
Mailing Address - Country:US
Mailing Address - Phone:810-636-2235
Mailing Address - Fax:810-636-3008
Practice Address - Street 1:7477 S STATE RD
Practice Address - Street 2:
Practice Address - City:GOODRICH
Practice Address - State:MI
Practice Address - Zip Code:48438-8745
Practice Address - Country:US
Practice Address - Phone:810-636-2235
Practice Address - Fax:810-636-3008
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3236035Medicaid
MIB46047Medicare UPIN
MIM23560016Medicare PIN