Provider Demographics
NPI:1902992837
Name:CLARK, JACK O (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:O
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2048
Mailing Address - Country:US
Mailing Address - Phone:208-359-6419
Mailing Address - Fax:208-356-3111
Practice Address - Street 1:450 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-359-6419
Practice Address - Fax:208-356-3111
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7743207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID10018055OtherREGENCE BCBS IDAHO
WY114780300Medicaid
ID80633500Medicaid
ID58289OtherBLUE CROSS IDAHO
ID805499200Medicaid
ID10018055OtherREGENCE BCBS IDAHO
ID805499200Medicaid
ID1141829Medicare ID - Type UnspecifiedINDIVIDUAL PROV NUMBER
ID1253103Medicare ID - Type UnspecifiedMCARE GROUP NUMBER
IDDA3027Medicare ID - Type UnspecifiedRAILROAD MCARE - NON RHC
IDP00049069Medicare ID - Type UnspecifiedRAILROAD MCARE - NON RHC