Basic Information
| Provider Information | |||||||||
| NPI: | 1699739946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152300060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4129375726 | ||||||||
| FaxNumber: | 4129375706 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 JOHNSON RD | ||||||||
| Address2: | |||||||||
| City: | STEUBENVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439522300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402648287 | ||||||||
| FaxNumber: | 7402648622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35074431 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.