Active NPI
Jerrold A Clark, MD
- Anatomic Pathology & Clinical Pathology Physician
- Marietta, GA
National Provider Identifier
1700866324
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Anatomic Pathology & Clinical Pathology Physician
- License
- 026841
- Practice address
- 2275 Northwest Parkway SE
Suite 140
Marietta, GA 30067-9319 - Phone
- (770) 951-1793
- Fax
- (770) 612-3380
- NPI assigned
- Jan 19, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Blood Banking & Transfusion Medicine Physician | 207ZB0001X | 026841 | GA | |
| Anatomic Pathology & Clinical Pathology Physician | 207ZP0102X | 026841 | GA | Primary |
Addresses
Primary practice location
2275 Northwest Parkway SE
Suite 140
Marietta, GA 30067-9319
Mailing address
14275 Midway Rd
Suite 400
Addison, TX 75001-3614
Phone (770) 951-1793
Other identifiers 9
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 52235375 009 | Other | GA | BCBS MARIETTA |
| 345972 | Other | GA | WELLCARE |
| 202I220225 | Medicaid | GA | |
| 52235375 006 | Other | GA | BCBS MONROE |
| 581267100 | Other | GA | TRICARE |
| 000302112A | Medicaid | GA | |
| 52235375 008 | Other | GA | BCBS BLECKLEY |
| 52235375 005 | Other | GA | BCBS COLISEUM |
| 52235375 007 | Other | GA | BCBS MACON NORTHSIDE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 026841 | GA | MD | Anatomic Pathology & Clinical Pathology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1137628800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1432857600000",
"number": "1700866324",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "14275 MIDWAY RD",
"address_2": "SUITE 400",
"city": "ADDISON",
"state": "TX",
"postal_code": "750013614",
"telephone_number": "770-951-1793",
"fax_number": "610-271-4245"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2275 NORTHWEST PARKWAY SE",
"address_2": "SUITE 140",
"city": "MARIETTA",
"state": "GA",
"postal_code": "300679319",
"telephone_number": "770-951-1793",
"fax_number": "770-612-3380"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "JERROLD",
"middle_name": "A",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-01-19",
"last_updated": "2015-05-29",
"status": "A"
},
"taxonomies": [
{
"code": "207ZB0001X",
"taxonomy_group": "",
"desc": "Pathology, Blood Banking & Transfusion Medicine",
"state": "GA",
"license": "026841",
"primary": false
},
{
"code": "207ZP0102X",
"taxonomy_group": "",
"desc": "Pathology, Anatomic Pathology & Clinical Pathology",
"state": "GA",
"license": "026841",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS MARIETTA",
"identifier": "52235375 009",
"state": "GA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "WELLCARE",
"identifier": "345972",
"state": "GA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "202I220225",
"state": "GA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS MONROE",
"identifier": "52235375 006",
"state": "GA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "581267100",
"state": "GA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "000302112A",
"state": "GA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS BLECKLEY",
"identifier": "52235375 008",
"state": "GA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS COLISEUM",
"identifier": "52235375 005",
"state": "GA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS MACON NORTHSIDE",
"identifier": "52235375 007",
"state": "GA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Marietta, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.