Provider Demographics
NPI:1225437759
Name:RICHARD CLARKE
Entity Type:Organization
Organization Name:RICHARD CLARKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ANESTHESIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CARLISLE
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-876-8054
Mailing Address - Street 1:7421 LAKE MICALA DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5823
Mailing Address - Country:US
Mailing Address - Phone:361-876-8054
Mailing Address - Fax:
Practice Address - Street 1:7421 LAKE MICALA DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-5823
Practice Address - Country:US
Practice Address - Phone:361-876-8054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA234604207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA155855301Medicaid