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General NPI Number Information
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NPI Number | 1902992837
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Entity Type | Individual
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Provider Name | JACK O. CLARK M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 04/13/2020
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Provider Practice Location Address
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Address Line | 450 E MAIN ST
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City | REXBURG
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State | ID
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Zip | 83440
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Country | US
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Telephone | 208-359-6419
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Fax | 208-356-3111
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Provider Business Mailing Address
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Address Line | 450 E MAIN ST
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City | REXBURG
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State | ID
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Zip | 83440-2048
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Country | US
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Telephone | 208-359-6419
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Fax | 208-356-3111
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | M-7743
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License Number State | ID
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