MEDICARE: MICHAEL JEFFERY 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	207X00000X	Orthopaedic Surgery Physician	4879	GA
2	207X00000X	Orthopaedic Surgery Physician	069783	GA
3	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician	069783	GA

General Provider Information

NPI Number	:	1407143381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL JEFFERY CLARK M.D.

Provider Business Mailing Address
First Line	:	5671 PEACHTREE DUNWOODY RD.
Second Line	:	SUITE 900
City	:	ATLANTA
State	:	GA
Zip	:	30342
Country	:	US
Telephone Number	:	404-847-9999
Fax Number	:

Provider Business Practice Location Address
First Line	:	5671 PEACHTREE DUNWOODY STE 700
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-5047
Country	:	US
Telephone Number	:	404-847-9999
Fax Number	:

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

Provider Enumeration Date	:	06/29/2011
Last Update Date	:	10/31/2017

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