Provider Demographics
NPI:1528028925
Name:CLARK, MICHAEL DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DEAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1838 AMERICAN WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6611
Mailing Address - Country:US
Mailing Address - Phone:770-995-7622
Mailing Address - Fax:770-995-7854
Practice Address - Street 1:5669 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1786
Practice Address - Country:US
Practice Address - Phone:404-256-0404
Practice Address - Fax:404-847-0423
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0225272086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00239368KMedicaid
GAD45071Medicare UPIN
GA77BBBJPMedicare PIN