Provider Demographics
NPI:1295922052
Name:CLARK, JILL ELISABETH (MD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:ELISABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JILL
Other - Middle Name:ELISABETH
Other - Last Name:WALDRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1035 116TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:715 DR MARTIN LUTHER KING JR AVE NE STE 301
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3668
Practice Address - Country:US
Practice Address - Phone:505-727-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61161110208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1295922052Medicaid