Provider Demographics
NPI:1619134970
Name:CLARK, MICHAEL JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JONATHAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M
Other - Middle Name:JONATHAN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2401 UNIVERSITY PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2894
Mailing Address - Country:US
Mailing Address - Phone:941-355-2767
Mailing Address - Fax:941-355-0617
Practice Address - Street 1:420 NOKOMIS AVE S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2617
Practice Address - Country:US
Practice Address - Phone:941-355-2767
Practice Address - Fax:941-355-0617
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT186642207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology