Provider Demographics
NPI:1346280005
Name:CLARK, JERRY A (MD, CMD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD, CMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 N FAIRFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-5918
Mailing Address - Country:US
Mailing Address - Phone:937-208-7000
Mailing Address - Fax:937-208-7010
Practice Address - Street 1:722 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-5918
Practice Address - Country:US
Practice Address - Phone:937-208-7000
Practice Address - Fax:937-208-7010
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.054620207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0647796Medicaid
OH0647796Medicaid
OH0625811Medicare PIN
OH0625812Medicare PIN