Provider Demographics
NPI:1306105986
Name:CLARK, MICHAEL ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1000 S HILL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-4455
Mailing Address - Country:US
Mailing Address - Phone:855-701-7955
Mailing Address - Fax:805-477-6693
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:GME OFFICE CSP 21005
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-9532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1300262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program