Healthcare Provider Details

I. General information

NPI: 1619141462
Provider Name (Legal Business Name): MICHAEL W CLISHAM DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6304 KENWOOD AVE 3
BALTIMORE MD
21237
US

IV. Provider business mailing address

6304 KENWOOD AVE 3
BALTIMORE MD
21237
US

V. Phone/Fax

Practice location:
  • Phone: 443-460-0127
  • Fax: 410-866-6610
Mailing address:
  • Phone: 443-460-0127
  • Fax: 410-866-6610

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: DR. MICHAEL WILLIAM CLISHAM
Title or Position: PODIATRIST
Credential: DPM
Phone: 443-460-0127