Provider Demographics
NPI:1982685459
Name:CLARK, MICHAEL H (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:ME
Mailing Address - Zip Code:04553-3838
Mailing Address - Country:US
Mailing Address - Phone:207-563-3366
Mailing Address - Fax:207-563-3393
Practice Address - Street 1:80 RIVER ROAD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:ME
Practice Address - Zip Code:04553-3838
Practice Address - Country:US
Practice Address - Phone:207-563-3366
Practice Address - Fax:207-563-3393
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME16528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431565400Medicaid
MEME1127Medicare ID - Type Unspecified
ME431565400Medicaid