Provider Demographics
NPI:1225268907
Name:CLARK, EDWARD WILLIAMS (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:WILLIAMS
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:E.
Other - Middle Name:WILL
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 600931
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75360-0931
Mailing Address - Country:US
Mailing Address - Phone:214-509-7054
Mailing Address - Fax:972-472-0998
Practice Address - Street 1:2704 PURDUE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-7909
Practice Address - Country:US
Practice Address - Phone:214-497-8559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP00262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry