MEDICARE: DR. MARK DANIEL CLARK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician	4301055514	MI
2	208D00000X	General Practice Physician	4301055514	MI
3	208VP0014X	Interventional Pain Medicine Physician	4301055514	MI
4	208VP0000X	Pain Medicine Physician	4301055514	MI

General Provider Information

NPI Number	:	1205989605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK DANIEL CLARK M.D.

Provider Business Mailing Address
First Line	:	3735 NORTON HILLS RD
Second Line	:
City	:	NORTON SHORES
State	:	MI
Zip	:	49441-4469
Country	:	US
Telephone Number	:	231-780-0484
Fax Number	:

Provider Business Practice Location Address
First Line	:	3735 NORTON HILLS RD
Second Line	:
City	:	NORTON SHORES
State	:	MI
Zip	:	49441-4469
Country	:	US
Telephone Number	:	231-780-0484
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	11/29/2022

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