MEDICARE: STACIE CLARK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207N00000X	Dermatology Physician	4301117007	MI

General Provider Information

NPI Number	:	1558756833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE CLARK M.D.

Provider Business Mailing Address
First Line	:	6700 N ROCHESTER RD STE 112
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48306-4378
Country	:	US
Telephone Number	:	248-650-1510
Fax Number	:

Provider Business Practice Location Address
First Line	:	6700 N ROCHESTER RD STE 112
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48306-4378
Country	:	US
Telephone Number	:	248-650-1510
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2015
Last Update Date	:	01/05/2020

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Directions to “ STACIE CLARK M.D.” Practice Location

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