Provider Demographics
NPI:1700866324
Name:CLARK, JERROLD A (MD)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:770-951-1793
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:2275 NORTHWEST PARKWAY SE
Practice Address - Street 2:SUITE 140
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9319
Practice Address - Country:US
Practice Address - Phone:770-951-1793
Practice Address - Fax:770-612-3380
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2015-05-29
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Provider Licenses
StateLicense IDTaxonomies
GA026841207ZB0001X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52235375 009OtherBCBS MARIETTA
GA345972OtherWELLCARE
GA202I220225Medicaid
GA52235375 006OtherBCBS MONROE
GA581267100OtherTRICARE
GA000302112AMedicaid
GA52235375 008OtherBCBS BLECKLEY
GA52235375 005OtherBCBS COLISEUM
GA52235375 007OtherBCBS MACON NORTHSIDE
GA345972OtherWELLCARE
GA000302112AMedicaid
GA52235375 005OtherBCBS COLISEUM