Healthcare Provider Details

I. General information

NPI: 1033437330
Provider Name (Legal Business Name): JONATHAN CLARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK BLVD STE 300E
BRISTOL TN
37620-7497
US

IV. Provider business mailing address

1 MEDICAL PARK BLVD STE 300E
BRISTOL TN
37620-7497
US

V. Phone/Fax

Practice location:
  • Phone: 423-844-6450
  • Fax: 423-844-6499
Mailing address:
  • Phone: 423-844-6450
  • Fax: 423-844-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number54727
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0101270907
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME123118
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: