Individual
JACK O. CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
450 E MAIN ST, REXBURG, ID 83440
(208) 359-6419
(208) 356-3111
Mailing address
450 E MAIN ST, REXBURG, ID 83440-2048
(208) 359-6419
(208) 356-3111
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
M-7743
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10018055
REGENCE BCBS IDAHO
ID
05
—
114780300
—
WY
01
—
58289
BLUE CROSS IDAHO
ID
05
—
805499200
—
ID
05
—
80633500
—
ID
Enumeration date
10/05/2006
Last updated
04/13/2020
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