Healthcare Provider Details

I. General information

NPI: 1366546749
Provider Name (Legal Business Name): MICHAEL CLISHAM DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6304 KENWOOD AVE 3
BALTIMORE MD
21237-2002
US

IV. Provider business mailing address

4100 CHARDEL RD APT A
NOTTINGHAM MD
21236-5457
US

V. Phone/Fax

Practice location:
  • Phone: 443-460-0127
  • Fax:
Mailing address:
  • Phone: 410-931-0726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00506
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: