Provider Demographics
NPI:1194839589
Name:CLARKE, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4202
Mailing Address - Country:US
Mailing Address - Phone:405-743-7300
Mailing Address - Fax:405-743-7398
Practice Address - Street 1:1815 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4202
Practice Address - Country:US
Practice Address - Phone:405-743-7300
Practice Address - Fax:405-743-7398
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1730673 01Medicaid
75-2600824OtherEIN: NORTH TEXAS MEDICAL-
TX1730673 01Medicaid
TXB6152Medicare ID - Type Unspecified