Provider Demographics
NPI:1952563611
Name:CLARK, JAMEEL TAMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMEEL
Middle Name:TAMIR
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-272-5395
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:4420 DIXIE HWY STE 126
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2994
Practice Address - Country:US
Practice Address - Phone:502-810-3780
Practice Address - Fax:502-394-3607
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002969208000000X
TN47695208000000X
KYTP415208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1525008Medicaid