Provider Demographics
NPI:1508033747
Name:CLARK, JASON (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
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 1:601 DANIELS BR
Mailing Address - Street 2:
Mailing Address - City:SITKA
Mailing Address - State:KY
Mailing Address - Zip Code:41255-8925
Mailing Address - Country:US
Mailing Address - Phone:606-792-6220
Mailing Address - Fax:
Practice Address - Street 1:290 BIG RUN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2903
Practice Address - Country:US
Practice Address - Phone:859-278-9513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41626207ZP0102X
NC01929207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
K105140Medicare PIN