Individual
JERRY RANDALL CLARK
Active
Individual
JERRY RANDALL CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
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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