Jack Prow Clark, M.D.
Individual provider Active NPI Family Medicine Physician · Syracuse, IN
NPI 1346320140 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1346320140
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 01017687 (IN)
- Practice address
- 518 EMS D15 LN
Syracuse, IN 46567-8026 - Phone
- (574) 457-3292
- NPI assigned
- Oct 16, 2006
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 01017687 | IN | MD | Family Medicine Physician |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 01017687 | IN | Yes |
Addresses
Primary practice location
518 EMS D15 LN
Syracuse, IN 46567-8026
Mailing address
518 EMS D15 LN
Syracuse, IN 46567-8026
Phone (574) 457-3292
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 01017687B | Other | IN | CSR CERTIFICATE |
| AC2674922 | Other | IN | BNDD NUMBER |
| 01017687A | Other | IN | MEDICAL LICENSE |
Other providers in Syracuse, IN
- Brenda Bone
- Brandon Boyd
- Brandi Miller
- Shane M. Bullick
- Diana Maureen Byron
- Jodi S Clouse
- Olivia Cook
- Randall Steven Cory
- Christopher Craig
- Dr Rod Kaufman, Optometrist, Inc.
All providers in Syracuse, IN · Family Medicine Physician in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.