Healthcare Provider Details

I. General information

NPI: 1861026205
Provider Name (Legal Business Name): CLARK J OKULSKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15366 WINDMILL POINTE DR
GROSSE POINTE PARK MI
48230-1744
US

IV. Provider business mailing address

15366 WINDMILL POINTE DR
GROSSE POINTE PARK MI
48230-1744
US

V. Phone/Fax

Practice location:
  • Phone: 313-822-9650
  • Fax:
Mailing address:
  • Phone: 313-822-9650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number5101005838
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: