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General NPI Number Information
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NPI Number | 1063573319
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Entity Type | Individual
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Provider Name | RANDALL NORTON CLARK MD
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Gender | Male
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Dates
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Enumeration Date | 12/12/2006
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Last Update Date | 07/18/2025
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Provider Practice Location Address
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Address Line | 3980 CHICAGO DR SW STE 200
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City | GRANDVILLE
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State | MI
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Zip | 49418-1392
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Country | US
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Telephone | 616-381-5181
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Fax | 616-381-5178
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Provider Business Mailing Address
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Address Line | 3980 CHICAGO DR SW STE 200
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City | GRANDVILLE
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State | MI
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Zip | 49418-1392
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Country | US
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Telephone | 616-381-5181
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Fax | 616-381-5178
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | RC050413
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License Number State | MI
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