Provider Demographics
NPI:1497072227
Name:CLARK, MATTHEW TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TIMOTHY
Last Name:CLARK
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 1:129 VISION PARK BLVD STE 307
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3024
Mailing Address - Country:US
Mailing Address - Phone:936-321-5440
Mailing Address - Fax:369-271-3705
Practice Address - Street 1:129 VISION PARK BLVD STE 307
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3024
Practice Address - Country:US
Practice Address - Phone:936-321-5440
Practice Address - Fax:369-271-3705
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR2309207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology