Provider Demographics
NPI:1356323935
Name:CRAIG, CLARK W (MD)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:W
Last Name:CRAIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W OLLIE ST
Mailing Address - Street 2:
Mailing Address - City:LLANO
Mailing Address - State:TX
Mailing Address - Zip Code:78643-2628
Mailing Address - Country:US
Mailing Address - Phone:325-247-5040
Mailing Address - Fax:325-248-2108
Practice Address - Street 1:706 AVENUE G
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-5866
Practice Address - Country:US
Practice Address - Phone:830-693-8234
Practice Address - Fax:830-693-9090
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110940101OtherFIRSTCARE
TX136901903Medicaid
TX99367OtherSCOTT WHITE
TX136901908Medicaid
TX83015KOtherBCBS
F86717Medicare UPIN
TX136901903Medicaid
TX99367OtherSCOTT WHITE
TX83015KOtherBCBS