Provider Demographics
NPI:1093798217
Name:CLARK, ANTHONY ELMORE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:ELMORE
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 1:3510 N LOOP 1604 E
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-2303
Mailing Address - Country:US
Mailing Address - Phone:210-375-7790
Mailing Address - Fax:
Practice Address - Street 1:45 NE LOOP 410
Practice Address - Street 2:SUITE 400
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5832
Practice Address - Country:US
Practice Address - Phone:210-375-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4916207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1264178-04Medicaid
TXA72536Medicare UPIN
TX1264178-04Medicaid