Provider Demographics
NPI:1295819316
Name:CLARK, CAMILLE (MD)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:CLARK
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 1:7777 FOREST LN
Mailing Address - Street 2:#D550
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230
Mailing Address - Country:US
Mailing Address - Phone:972-566-7009
Mailing Address - Fax:972-566-6289
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:#D550
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:972-566-7009
Practice Address - Fax:972-566-6289
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4917207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C14521Medicare UPIN
TX877428Medicare ID - Type Unspecified