Provider Demographics
NPI:1619592748
Name:CHEN, CLARK JIA-LONG (MD)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:JIA-LONG
Last Name:CHEN
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 1:5401 OLD YORK RD # KLEIN101
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3030
Mailing Address - Country:US
Mailing Address - Phone:215-457-4444
Mailing Address - Fax:215-457-7602
Practice Address - Street 1:5401 OLD YORK RD # KLEIN101
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3030
Practice Address - Country:US
Practice Address - Phone:215-457-4444
Practice Address - Fax:215-457-7602
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT220670208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery