Individual
DR. JERROLD A CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2275 NORTHWEST PARKWAY SE, SUITE 140, MARIETTA, GA 30067-9319
(770) 951-1793
(770) 612-3380
Mailing address
14275 MIDWAY RD, SUITE 400, ADDISON, TX 75001-3614
(770) 951-1793
(610) 271-4245
Taxonomy
Speciality
Code
Description
License number
State
207ZB0001X
Blood Banking & Transfusion Medicine Physician
026841
GA
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
026841
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000302112A
—
GA
05
—
202I220225
—
GA
01
—
345972
WELLCARE
GA
01
—
52235375 005
BCBS COLISEUM
GA
01
—
52235375 006
BCBS MONROE
GA
01
—
52235375 007
BCBS MACON NORTHSIDE
GA
01
—
52235375 008
BCBS BLECKLEY
GA
01
—
52235375 009
BCBS MARIETTA
GA
01
—
581267100
TRICARE
GA
Enumeration date
01/19/2006
Last updated
05/29/2015
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