Provider Demographics
NPI:1033437330
Name:CLARK, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CLARK
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 1:1 MEDICAL PARK BLVD
Mailing Address - Street 2:STE 300E
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7497
Mailing Address - Country:US
Mailing Address - Phone:423-844-6450
Mailing Address - Fax:423-844-6499
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:STE 300E
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7497
Practice Address - Country:US
Practice Address - Phone:423-844-6450
Practice Address - Fax:423-844-6499
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME123118207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ023678Medicaid
FL014980500Medicaid
FLIG920ZMedicare PIN
TN103I207574Medicare PIN