Provider Demographics
NPI:1164401089
Name:CLARK, STEPHEN SIDNEY (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:SIDNEY
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 1:3705 MEDICAL PKWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1019
Mailing Address - Country:US
Mailing Address - Phone:512-334-1885
Mailing Address - Fax:
Practice Address - Street 1:3705 MEDICAL PKWY
Practice Address - Street 2:SUITE 250
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1019
Practice Address - Country:US
Practice Address - Phone:512-302-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD4955208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery