Individual
JUSTIN CHARLES CLARK
Active
Individual
JUSTIN CHARLES CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207T00000X
Neurological Surgery Physician
Primary
4301104141
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4301104141
STATE OF MICHIGAN
MI
01
—
80762
TRAINING PERMIT
AZ
Enumeration date
11/06/2007
Last updated
06/26/2015
Update your record
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