Provider Demographics
NPI:1962477216
Name:CLARK, JONATHAN R (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
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 65592
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-0592
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:105 WALL ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4433
Practice Address - Country:US
Practice Address - Phone:918-635-3400
Practice Address - Fax:918-635-3394
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2355207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E45382Medicare UPIN