Provider Demographics
NPI:1851373252
Name:CLARK, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 S RENFRO ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-4742
Mailing Address - Country:US
Mailing Address - Phone:336-789-9031
Mailing Address - Fax:336-789-8343
Practice Address - Street 1:602 S RENFRO ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4742
Practice Address - Country:US
Practice Address - Phone:336-789-9031
Practice Address - Fax:336-789-8343
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001250552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC580000014OtherPALMETTO GBA--RAILROAD MEDICARE
NC1409898OtherUNITED MINE WORKERS
5612703280002OtherCIGNA
NC8909154Medicaid
NC013MWOtherBCBS OF NC PROVIDER #
3739OtherBLUE MEDICARE HMO
NC0474540001Medicare NSC
5612703280002OtherCIGNA
NC246019Medicare PIN