Provider Demographics
NPI:1730289240
Name:CLARK, MEGAN N (MD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:N
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:721 KENMOOR AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2306
Mailing Address - Country:US
Mailing Address - Phone:616-949-6112
Mailing Address - Fax:616-949-8530
Practice Address - Street 1:710 KENMOOR AVE SE
Practice Address - Street 2:SUITE 110
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2379
Practice Address - Country:US
Practice Address - Phone:616-949-6112
Practice Address - Fax:616-949-8530
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2022-11-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301065618208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3476828Medicaid