Basic Information
| Provider Information | |||||||||
| NPI: | 1700866324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JERROLD | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709511793 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 2275 NORTHWEST PARKWAY SE | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300679319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709511793 | ||||||||
| FaxNumber: | 7706123380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 05/29/2015 | ||||||||
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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 | 207ZB0001X | 026841 | GA | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZP0102X | 026841 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 52235375 009 | 01 | GA | BCBS MARIETTA | OTHER | 345972 | 01 | GA | WELLCARE | OTHER | 202I220225 | 05 | GA | MEDICAID | 52235375 006 | 01 | GA | BCBS MONROE | OTHER | 581267100 | 01 | GA | TRICARE | OTHER | 000302112A | 05 | GA | MEDICAID | 52235375 008 | 01 | GA | BCBS BLECKLEY | OTHER | 52235375 005 | 01 | GA | BCBS COLISEUM | OTHER | 52235375 007 | 01 | GA | BCBS MACON NORTHSIDE | OTHER |