MEDICARE: JACK DOUGLAS CLARK M.D.

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	G56196	CA

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	:	1265571608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK DOUGLAS CLARK M.D.

Provider Business Mailing Address
First Line	:	7112 N FRESNO ST
Second Line	:	SUITE 100
City	:	FRESNO
State	:	CA
Zip	:	93720-2940
Country	:	US
Telephone Number	:	559-439-1620
Fax Number	:	559-432-6579

Provider Business Practice Location Address
First Line	:	7112 N FRESNO ST
Second Line	:	SUITE 100
City	:	FRESNO
State	:	CA
Zip	:	93720-2940
Country	:	US
Telephone Number	:	559-439-1620
Fax Number	:	559-432-6579

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

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	07/08/2007

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