Healthcare Provider Details

I. General information

NPI: 1457907321
Provider Name (Legal Business Name): JEFFREY CLARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S WOOD ST STE 100
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

820 S WOOD ST STE 100
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-2933
  • Fax:
Mailing address:
  • Phone: 312-996-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number125.087172
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: