Provider Demographics
NPI:1811166572
Name:CLARK, JESSE LAWTON (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:LAWTON
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 1:200 MEDICAL PLAZA
Mailing Address - Street 2:SUITE 365
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-0000
Mailing Address - Country:US
Mailing Address - Phone:310-301-8708
Mailing Address - Fax:
Practice Address - Street 1:5767 W CENTURY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-5632
Practice Address - Country:US
Practice Address - Phone:310-301-8708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95103207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A951030Medicaid
CAAQ404ZMedicare PIN