Healthcare Provider Details

I. General information

NPI: 1457662280
Provider Name (Legal Business Name): MICHAEL LEE CLARK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2010
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13813 METRO PKWY
FORT MYERS FL
33912-4343
US

IV. Provider business mailing address

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 855-674-4624
  • Fax: 941-883-8386
Mailing address:
  • Phone: 877-856-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036132955
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS13601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: