Provider Demographics
NPI:1205989605
Name:CLARK, MARK DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DANIEL
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 1:3735 NORTON HILLS RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4469
Mailing Address - Country:US
Mailing Address - Phone:231-780-0484
Mailing Address - Fax:
Practice Address - Street 1:3735 NORTON HILLS RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-4469
Practice Address - Country:US
Practice Address - Phone:231-780-0484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055514207LP2900X, 208D00000X, 208VP0014X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164664082Medicaid
MIMI1779003Medicare PIN