Provider Demographics
NPI:1538115423
Name:CLARK, MICHAEL B (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2002 MEDICAL PKWY
Mailing Address - Street 2:STE 235
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3046
Mailing Address - Country:US
Mailing Address - Phone:410-266-2770
Mailing Address - Fax:410-841-6251
Practice Address - Street 1:2002 MEDICAL PKWY
Practice Address - Street 2:STE 235
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3046
Practice Address - Country:US
Practice Address - Phone:410-266-2770
Practice Address - Fax:410-841-6251
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-02-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD00561832085R0204X, 2085N0700X
OH35.0803582085R0202X
PAMD4169762085R0202X
NC2000001982085R0202X
SC283022085R0202X
FLME947002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDN899OtherAAD AA COUNTY
MD019419A80OtherAAD PG COUNTY
MD2622593OtherAETNA HMO/POS
MD017000300Medicaid
MD8317071OtherAETNA PPO
MD10690029OtherBCBS
MDN899OtherAAD AA COUNTY
MDH21304Medicare UPIN
MDP00307060Medicare PIN
MD8317071OtherAETNA PPO