Individual
DR. MICHAEL CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
602 S RENFRO ST, MOUNT AIRY, NC 27030-4742
(336) 789-9031
(336) 789-8343
Mailing address
602 S RENFRO ST, MOUNT AIRY, NC 27030-4742
(336) 789-9031
(336) 789-8343
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
200001250552
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
013MW
BCBS OF NC PROVIDER #
NC
01
—
1409898
UNITED MINE WORKERS
NC
01
—
3739
BLUE MEDICARE HMO
—
01
—
5612703280002
CIGNA
—
01
—
580000014
PALMETTO GBA--RAILROAD MEDICARE
NC
05
—
8909154
—
NC
Enumeration date
11/19/2005
Last updated
01/08/2014
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