Provider Demographics
NPI:1265571608
Name:CLARK, JACK DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:DOUGLAS
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 1:7112 N FRESNO ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2940
Mailing Address - Country:US
Mailing Address - Phone:559-439-1620
Mailing Address - Fax:559-432-6579
Practice Address - Street 1:7112 N FRESNO ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2940
Practice Address - Country:US
Practice Address - Phone:559-439-1620
Practice Address - Fax:559-432-6579
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56196207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G561960Medicaid
CA00G561960Medicare ID - Type Unspecified
CAE58400Medicare UPIN