Provider Demographics
NPI:1396881827
Name:CLARKSTON MEDICAL CLINIC PC
Entity type:Organization
Organization Name:CLARKSTON MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TARLIKA
Authorized Official - Middle Name:C
Authorized Official - Last Name:DHABUWALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-625-8220
Mailing Address - Street 1:5790 S MAIN STREET
Mailing Address - Street 2:STE J
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346
Mailing Address - Country:US
Mailing Address - Phone:248-625-8220
Mailing Address - Fax:248-625-6646
Practice Address - Street 1:5790 S MAIN STREET
Practice Address - Street 2:STE J
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-625-8220
Practice Address - Fax:248-625-6646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITD040084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0631128Medicare ID - Type Unspecified