Provider Demographics
NPI:1073665964
Name:CLARK, JAMES T (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:T
Last Name:CLARK
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 1:1100 E LAKE ST
Mailing Address - Street 2:SUITE 330
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-3343
Mailing Address - Country:US
Mailing Address - Phone:903-595-5522
Mailing Address - Fax:903-595-3834
Practice Address - Street 1:1100 E LAKE ST
Practice Address - Street 2:SUITE 330
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-3343
Practice Address - Country:US
Practice Address - Phone:903-595-5522
Practice Address - Fax:903-595-3834
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD3181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX751477994OtherTAX ID #
TX11235461Medicaid
TX041539337OtherRAILROAD MEDICARE
TX751477994OtherTAX ID #
TXC14514Medicare UPIN