Provider Demographics
NPI:1831105782
Name:CLARK, FRANK M (DO)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207
Mailing Address - Country:US
Mailing Address - Phone:313-579-1860
Mailing Address - Fax:313-579-0017
Practice Address - Street 1:3130 GRATIOT AVENUE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207
Practice Address - Country:US
Practice Address - Phone:313-579-1860
Practice Address - Fax:313-579-0017
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5974207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1127111Medicaid
E31650Medicare UPIN
MI1127111Medicaid