Provider Demographics
NPI:1073838850
Name:CLARK, JEREMY DUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DUSTIN
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 1:301 E MUHAMMAD ALI BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1511
Mailing Address - Country:US
Mailing Address - Phone:502-588-0550
Mailing Address - Fax:
Practice Address - Street 1:301 E MUHAMMAD ALI BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1511
Practice Address - Country:US
Practice Address - Phone:502-588-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY47098207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program