Basic Information
| Provider Information | |||||||||
| NPI: | 1528028925 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1838 AMERICAN WAY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300436611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709957622 | ||||||||
| FaxNumber: | 7709957854 | ||||||||
| Practice Location | |||||||||
| Address1: | 5669 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042560404 | ||||||||
| FaxNumber: | 4048470423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 08/23/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 022527 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00239368K | 05 | GA | MEDICAID |