Provider Demographics
NPI:1780803023
Name:CLARK, RAY HOWARD (MD)
Entity type:Individual
Prefix:DR
First Name:RAY
Middle Name:HOWARD
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 1:1976 Q LN
Mailing Address - Street 2:
Mailing Address - City:CLARKLAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49234-9747
Mailing Address - Country:US
Mailing Address - Phone:517-529-4168
Mailing Address - Fax:
Practice Address - Street 1:1100 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1847
Practice Address - Country:US
Practice Address - Phone:517-789-7122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301025864207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology