Provider Demographics
NPI:1588717417
Name:CLARK, JEREMY J (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S JACKSON ST FL 2
Mailing Address - Street 2:DEPT OB/GYN ATT VICKI MASTERSON
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 E CHESTNUT ST
Practice Address - Street 2:SUITE 410
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5700
Practice Address - Country:US
Practice Address - Phone:502-271-5999
Practice Address - Fax:502-271-5994
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41069207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000001568FOtherHUMANA PSC
KY000000542980OtherANTHEM - PSC
KY50016302OtherPASSPORT SPECIALITY# -FOUNDATION
KY50016301OtherPASSPORT SPECIALITY - PSC
KY50017315OtherPASSPORT PCP# - FOUNDATION
KY7100013410Medicaid
7290926OtherAETNA
IN200868450Medicaid
KY000000522820OtherANTHEM FOUNDATION
000001172TOtherHUMANA FOUNDATION
000001172TOtherHUMANA FOUNDATION
KY0979709Medicare PIN