Provider Demographics
NPI:1346391752
Name:CLARK, SAMUEL DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:DAVID
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HILLCREST MEDICAL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8948
Mailing Address - Country:US
Mailing Address - Phone:254-297-0400
Mailing Address - Fax:
Practice Address - Street 1:120 HILLCREST MEDICAL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8948
Practice Address - Country:US
Practice Address - Phone:254-297-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4354208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics