1619134970 NPI number — DR. MICHAEL JONATHAN CLARK M.D.

Table of content: DR. MICHAEL JONATHAN CLARK M.D. (NPI 1619134970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619134970 NPI number — DR. MICHAEL JONATHAN CLARK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
MICHAEL
Provider Middle Name:
JONATHAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
M
Provider Other Middle Name:
JONATHAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1619134970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 UNIVERSITY PKWY STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34243-2894
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-355-2767
Provider Business Mailing Address Fax Number:
941-355-0617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 NOKOMIS AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34285-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-355-2767
Provider Business Practice Location Address Fax Number:
941-355-0617
Provider Enumeration Date:
05/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  MT186642 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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