Individual
JERRY RANDALL CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
MEDICAL CENTER BLVD, WINSTON SALEM, NC 27157-0001
(336) 716-2255
Mailing address
PO BOX 344, WINSTON SALEM, NC 27102-0344
(336) 716-2255
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
200200013
NC
207LP2900X
Pain Medicine (Anesthesiology) Physician
200200013
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
050086653
RR MEDICARE
—
01
—
1302E
BCBS
—
05
—
1840960000
—
VA
01
—
46553
PARTNERS
—
01
—
7543615
AETNA
—
05
—
891302E
—
NC
01
—
B4294
MEDCOST
—
05
—
Q00012
—
SC
Enumeration date
12/13/2005
Last updated
08/23/2017
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