Provider Demographics
NPI:1427174374
Name:CLARK, SONYA MICIAK (DO)
Entity type:Individual
Prefix:DR
First Name:SONYA
Middle Name:MICIAK
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:770 W GRANADA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5179
Mailing Address - Country:US
Mailing Address - Phone:386-231-4519
Mailing Address - Fax:386-368-8927
Practice Address - Street 1:600 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7327
Practice Address - Country:US
Practice Address - Phone:386-424-6845
Practice Address - Fax:386-424-3847
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2025-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS22614207XS0106X
NC2016-02120207XS0106X
SC32951207X00000X, 207XS0106X, 207XS0106X
TN2121207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519420Medicaid
MS04301531Medicaid
MS04301531Medicaid
MS433787YJ5DMedicare PIN