Individual
JONATHAN SCOTT CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
1103 DEWEY AVE, POTEAU, OK 74953-4411
(918) 649-3777
(918) 649-3891
Mailing address
PO BOX 1236, POTEAU, OK 74953-1236
(918) 649-3777
(918) 649-3891
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
3561
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100114570B
—
OK
01
—
P00061421
RAILROAD MEDICARE
OK
Enumeration date
05/03/2006
Last updated
03/11/2011
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