Provider Demographics
NPI:1831484138
Name:CLARK, JOHN MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
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 1:100 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:484-476-2000
Mailing Address - Fax:
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:484-580-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS019297207RC0000X, 207RA0001X
PAOT013929207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine