Provider Demographics
NPI:1073595708
Name:BRAZIL, CLARK WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:WESLEY
Last Name:BRAZIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4401
Mailing Address - Country:US
Mailing Address - Phone:940-322-6671
Mailing Address - Fax:940-322-6676
Practice Address - Street 1:1508 10TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4401
Practice Address - Country:US
Practice Address - Phone:940-322-6671
Practice Address - Fax:940-322-6676
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE15122086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1281834-01Medicaid
TXB21478Medicare UPIN
TX1281834-01Medicaid