Provider Demographics
NPI:1184682866
Name:CLARK, JONATHAN SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SCOTT
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1236
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-1236
Mailing Address - Country:US
Mailing Address - Phone:918-649-3777
Mailing Address - Fax:918-649-3891
Practice Address - Street 1:1103 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4411
Practice Address - Country:US
Practice Address - Phone:918-649-3777
Practice Address - Fax:918-649-3891
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00061421OtherRAILROAD MEDICARE
OK100114570BMedicaid
OKG92053Medicare UPIN
OK100114570BMedicaid