Provider Demographics
NPI:1003873779
Name:JERNIGAN, W. CLARK (MD)
Entity Type:Individual
Prefix:DR
First Name:W.
Middle Name:CLARK
Last Name:JERNIGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 HIGHWAY 153
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-9498
Mailing Address - Country:US
Mailing Address - Phone:864-295-1231
Mailing Address - Fax:864-295-0095
Practice Address - Street 1:3150 HIGHWAY 153
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SC
Practice Address - Zip Code:29673-9498
Practice Address - Country:US
Practice Address - Phone:864-295-1231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10939207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC109395Medicaid
SC8157OtherMEDICARE PTAN
SCD99376Medicare UPIN
SC109395Medicaid