MEDICARE: JESSE LAWTON 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	207R00000X	Internal Medicine Physician	A95103	CA
2	207RI0200X	Infectious Disease Physician	A95103	CA
3	207Q00000X	Family Medicine Physician	A95103	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	:	1811166572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE LAWTON CLARK M.D.

Provider Business Mailing Address
First Line	:	5767 W CENTURY BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5631
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 VINE ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90038-2702
Country	:	US
Telephone Number	:	323-461-3106
Fax Number	:

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

Provider Enumeration Date	:	02/27/2008
Last Update Date	:	06/10/2026

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