Basic Information
| Provider Information | |||||||||
| NPI: | 1649421132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 SE MAGNOLIA EXT | ||||||||
| Address2: | UNIT 1 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344713770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524011218 | ||||||||
| FaxNumber: | 3524011017 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 SE MAGNOLIA EXT | ||||||||
| Address2: | UNIT 1 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344713770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524011218 | ||||||||
| FaxNumber: | 3524011017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME111874 | FL | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0105X | ME111874 | FL | N | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | 2086S0127X | ME111874 | FL | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0102X | ME111874 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 007273600 | 05 | FL | MEDICAID |