Provider Demographics
NPI:1366546749
Name:CLISHAM, MICHAEL (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:CLISHAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 CHARDEL RD APT A
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-5457
Mailing Address - Country:US
Mailing Address - Phone:410-931-0726
Mailing Address - Fax:
Practice Address - Street 1:6304 KENWOOD AVE
Practice Address - Street 2:3
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-2002
Practice Address - Country:US
Practice Address - Phone:443-460-0127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00506213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1122910001Medicare NSC
MD1619141462Medicare NSC