Provider Demographics
NPI:1609874569
Name:CLARKE, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:CLARKE
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 1:3150 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7301
Mailing Address - Country:US
Mailing Address - Phone:417-881-5529
Mailing Address - Fax:417-885-3921
Practice Address - Street 1:3150 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7301
Practice Address - Country:US
Practice Address - Phone:417-881-5529
Practice Address - Fax:417-885-3921
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO32388174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200505824Medicaid
431552300OtherTRICARE WEST
201077503OtherPALMETTO GBA
MOOOOOO8481Medicare ID - Type Unspecified
0722010001Medicare NSC
MO200505824Medicaid