Provider Demographics
NPI:1831143601
Name:CLARK, JEFFREY ALAN (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
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 2758
Mailing Address - Street 2:4150 KIMBALL AVENUE
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-235-5390
Mailing Address - Fax:319-235-5607
Practice Address - Street 1:2351 HUDSON ROAD
Practice Address - Street 2:SUITE 001
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50614-0001
Practice Address - Country:US
Practice Address - Phone:319-273-5275
Practice Address - Fax:319-273-5295
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3304207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0215665Medicaid
IA19423OtherWELLMARK INS PLAN
IA421417307E4OtherJOHN DEERE HEALTH INS
H17249Medicare UPIN
IA19423Medicare PIN