Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 069783 | GA |
N | 207X00000X | Orthopaedic Surgeon | 4879 | GA |
Y | 207XX0004X | Foot and Ankle Orthopaedic Surgeon | 069783 | GA |
NPI | 1407143381 |
---|---|
Provider Name | Michael Jeffery Clark |
First Address | Atlanta, GA 30342 |
Second Address | Atlanta, GA 30342-5047 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2011 |
Last Update Date | 31/10/2017 |