Healthcare Provider Details

I. General information

NPI: 1548220700
Provider Name (Legal Business Name): CLARK PETER JOHNSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 NORTH AVE
BATTLE CREEK MI
49017-3430
US

IV. Provider business mailing address

213 NORTH AVE
BATTLE CREEK MI
49017-3430
US

V. Phone/Fax

Practice location:
  • Phone: 269-968-6000
  • Fax: 269-968-3015
Mailing address:
  • Phone: 269-968-6000
  • Fax: 269-968-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901000962
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number5901000962
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number5901000962
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: