Individual
DR. JACK PROW CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
518 EMS D15 LN, SYRACUSE, IN 46567-8026
(574) 457-3292
Mailing address
518 EMS D15 LN, SYRACUSE, IN 46567-8026
(574) 457-3292
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01017687
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01017687A
MEDICAL LICENSE
IN
01
—
01017687B
CSR CERTIFICATE
IN
01
—
AC2674922
BNDD NUMBER
IN
Enumeration date
10/16/2006
Last updated
07/08/2007
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