Provider Demographics
NPI:1700183993
Name:CLARK, MICHAEL BRADY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRADY
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 1:1400 MCKEAN RD
Mailing Address - Street 2:PO BOX 776
Mailing Address - City:SPRING HOUSE
Mailing Address - State:PA
Mailing Address - Zip Code:19477
Mailing Address - Country:US
Mailing Address - Phone:215-793-7131
Mailing Address - Fax:
Practice Address - Street 1:1400 MCKEAN RD
Practice Address - Street 2:
Practice Address - City:SPRING HOUSE
Practice Address - State:PA
Practice Address - Zip Code:19477
Practice Address - Country:US
Practice Address - Phone:215-793-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010561492083A0100X
GA0551142083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine