Provider Demographics
NPI:1912903949
Name:CLARK, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:850 N MAIN STREET EXT
Mailing Address - Street 2:BLGD 2 SUITE C2
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2400
Mailing Address - Country:US
Mailing Address - Phone:203-269-9778
Mailing Address - Fax:203-949-1544
Practice Address - Street 1:850 N MAIN STREET EXT
Practice Address - Street 2:BLGD 2 SUITE C2
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2400
Practice Address - Country:US
Practice Address - Phone:203-269-9778
Practice Address - Fax:203-949-1544
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT41950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H97122Medicare UPIN
CT080001642Medicare ID - Type Unspecified