Provider Demographics
NPI:1255356150
Name:CLARK, JASON PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:PAUL
Last Name:CLARK
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:P.O. BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-2800
Mailing Address - Fax:214-645-2808
Practice Address - Street 1:5323 HARRY HINES BOULEVARD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:214-645-2800
Practice Address - Fax:214-645-2808
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7690207R00000X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179096602Medicaid
TX179096603Medicaid
TX8S3696OtherBCBS
TXTXB156018Medicare PIN
TX8K1369Medicare PIN
TX8S3696OtherBCBS