Provider Demographics
NPI:1497109888
Name:CLARK, MICHAEL DEAN JR
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DEAN
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 SAINT VINCENTS DR STE 403
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1614
Mailing Address - Country:US
Mailing Address - Phone:205-939-0447
Mailing Address - Fax:205-939-0418
Practice Address - Street 1:5850 VALLEY RD STE 110
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-8683
Practice Address - Country:US
Practice Address - Phone:205-838-3090
Practice Address - Fax:205-838-3043
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL44929207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program