Provider Demographics
NPI:1083698898
Name:CLARK, JERRY DOYLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DOYLE
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 1:3650 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-2216
Mailing Address - Country:US
Mailing Address - Phone:409-838-0346
Mailing Address - Fax:
Practice Address - Street 1:3650 LAUREL ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-2216
Practice Address - Country:US
Practice Address - Phone:409-838-0346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2345207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC14507Medicare UPIN
TX881603Medicare PIN