Provider Demographics
NPI:1942715255
Name:CLARK, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3192 MERRICK TERRACE
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063
Mailing Address - Country:US
Mailing Address - Phone:954-812-5661
Mailing Address - Fax:
Practice Address - Street 1:10600 RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-3307
Practice Address - Country:US
Practice Address - Phone:954-812-5661
Practice Address - Fax:954-812-5661
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16242081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine