Provider Demographics
NPI:1598945644
Name:CLARK, JUSTIN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CHARLES
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:414 PLYMOUTH NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6041
Mailing Address - Country:US
Mailing Address - Phone:616-454-3465
Mailing Address - Fax:616-242-7060
Practice Address - Street 1:414 PLYMOUTH NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-6041
Practice Address - Country:US
Practice Address - Phone:616-454-3465
Practice Address - Fax:616-242-7060
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2015-06-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301104141207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ80762OtherTRAINING PERMIT
MI4301104141OtherSTATE OF MICHIGAN