Provider Demographics
NPI:1306837620
Name:CLARK-KELLEY, MICHAELA J (DO)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:J
Last Name:CLARK-KELLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-7997
Mailing Address - Country:US
Mailing Address - Phone:207-621-8800
Mailing Address - Fax:207-621-8801
Practice Address - Street 1:15 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-7997
Practice Address - Country:US
Practice Address - Phone:207-621-8800
Practice Address - Fax:207-621-8801
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431974999Medicaid
CLME1402Medicare ID - Type Unspecified
ME431974999Medicaid