MEDICARE: DR. JEFFREY IRA 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	207R00000X	Internal Medicine Physician	016221	GA

General Provider Information

NPI Number	:	1316946957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY IRA CLARK MD

Provider Business Mailing Address
First Line	:	4890 ROSWELL RD NE
Second Line	:	SUITE 250
City	:	ATLANTA
State	:	GA
Zip	:	30342-2606
Country	:	US
Telephone Number	:	404-255-9244
Fax Number	:	404-255-9114

Provider Business Practice Location Address
First Line	:	4890 ROSWELL RD NE
Second Line	:	SUITE 250
City	:	ATLANTA
State	:	GA
Zip	:	30342-2606
Country	:	US
Telephone Number	:	404-255-9244
Fax Number	:	404-255-9114

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	11/10/2015

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