MEDICARE: JACOB A CLARK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	0101041044	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164464806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB A CLARK MD

Provider Business Mailing Address
First Line	:	2661 RIVA RD STE 1030
Second Line	:
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-7131
Country	:	US
Telephone Number	:	410-571-8733
Fax Number	:	410-571-6309

Provider Business Practice Location Address
First Line	:	411 N WASHINGTON ST
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-2311
Country	:	US
Telephone Number	:	703-548-5588
Fax Number	:	703-549-1599

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2006
Last Update Date	:	01/21/2026

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