Healthcare Provider Details

I. General information

NPI: 1457733719
Provider Name (Legal Business Name): CLARK CHEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 01/04/2023
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 W BIG BEAVER RD STE 520
TROY MI
48084-3442
US

IV. Provider business mailing address

2080 W EMPIRE AVE # 1080
BURBANK CA
91504-3434
US

V. Phone/Fax

Practice location:
  • Phone: 248-646-6659
  • Fax:
Mailing address:
  • Phone: 818-937-3399
  • Fax: 818-514-7897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS14427
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101024209
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number19576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: