Michael Dwayne Clark
Individual provider Active NPI Driver · Lake Charles, LA
NPI 1063683597 · NPPES record last updated Mar 12, 2008
Key facts
- NPI
- 1063683597
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Driver 172A00000X
- Practice address
- 619 Clarence St Apt 5
Lake Charles, LA 70601-5370 - Phone
- (337) 721-8070
- Fax
- (337) 721-8060
- NPI assigned
- Mar 12, 2008
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 005916431 | LA | MD | Driver |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Driver | 172A00000X | LA | Yes |
Addresses
Primary practice location
619 Clarence St Apt 5
Lake Charles, LA 70601-5370
Mailing address
619 Clarence St Apt 5
Lake Charles, LA 70601-5370
Phone (337) 721-8070
Other providers in Lake Charles, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 12, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.