Provider Demographics
NPI:1932602125
Name:JAGGARD, CLARENCE WILLIAM JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:WILLIAM
Last Name:JAGGARD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5571 NORTH 21ST ST.
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721
Mailing Address - Country:US
Mailing Address - Phone:417-317-5330
Mailing Address - Fax:417-763-3370
Practice Address - Street 1:OZARK VALLEY MEDICAL CLINIC 5571 N. 21ST ST.
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721
Practice Address - Country:US
Practice Address - Phone:417-317-5330
Practice Address - Fax:417-763-3370
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2017039470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202204519OtherPHARMACY LICENSE
MO2017039470OtherASSISTANT PHYSICIAN LICENSE
VAT61723021OtherDRIVERS LICENSE NUMBER