Provider Demographics
NPI:1508939877
Name:CLARK, MICHAEL JAMES (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 BARKER ST
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-4808
Mailing Address - Country:US
Mailing Address - Phone:772-567-0771
Mailing Address - Fax:772-567-0575
Practice Address - Street 1:2706 20TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3001
Practice Address - Country:US
Practice Address - Phone:772-567-0771
Practice Address - Fax:772-567-0575
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH-00003973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT85848Medicare UPIN
FL88064Medicare ID - Type Unspecified