Provider Demographics
NPI:1710075023
Name:CLARK, LORRAINE (D O)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6149 N WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-7128
Mailing Address - Country:US
Mailing Address - Phone:734-728-2130
Mailing Address - Fax:734-728-2626
Practice Address - Street 1:6149 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-7128
Practice Address - Country:US
Practice Address - Phone:734-728-2130
Practice Address - Fax:734-728-2626
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008704207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4835287Medicaid