Provider Demographics
NPI:1609859040
Name:CLARK, JOHN L JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:CLARK
Suffix:JR
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:PO BOX 12610
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71315-2610
Mailing Address - Country:US
Mailing Address - Phone:318-767-1543
Mailing Address - Fax:318-767-1110
Practice Address - Street 1:1405 METRO DR
Practice Address - Street 2:BLDG L
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3448
Practice Address - Country:US
Practice Address - Phone:318-767-1543
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD021955208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1682136Medicaid