Provider Demographics
NPI:1407014855
Name:GLORIA CLARK, MD PA
Entity Type:Organization
Organization Name:GLORIA CLARK, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORAI
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-598-7900
Mailing Address - Street 1:10201 GATEWAY BLVD W
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7652
Mailing Address - Country:US
Mailing Address - Phone:915-598-7900
Mailing Address - Fax:915-598-7902
Practice Address - Street 1:10201 GATEWAY BLVD W
Practice Address - Street 2:SUITE 400
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7652
Practice Address - Country:US
Practice Address - Phone:915-598-7900
Practice Address - Fax:915-598-7902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-01
Last Update Date:2008-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8961207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096531102Medicaid
TXG12132Medicare UPIN