Provider Demographics
NPI:1538152749
Name:CLARK, MAX A (DO)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 MIAMISBURG CENTERVILLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3811
Mailing Address - Country:US
Mailing Address - Phone:937-438-1340
Mailing Address - Fax:937-438-4802
Practice Address - Street 1:1975 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-3811
Practice Address - Country:US
Practice Address - Phone:937-438-1340
Practice Address - Fax:937-438-4802
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003865207VG0400X, 207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Not Answered207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0803367Medicaid
OH0803367Medicaid