Provider Demographics
NPI:1164464806
Name:CLARK, JACOB A (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:A
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 1:411 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2311
Mailing Address - Country:US
Mailing Address - Phone:703-548-5588
Mailing Address - Fax:703-549-1599
Practice Address - Street 1:411 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2311
Practice Address - Country:US
Practice Address - Phone:703-548-5588
Practice Address - Fax:703-549-1599
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041044207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6375570Medicaid
C89098Medicare UPIN
448387Medicare ID - Type Unspecified
VA6375570Medicaid