Provider Demographics
NPI:1508263732
Name:DRIVER, CLARK
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:DRIVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 W MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4250
Mailing Address - Country:US
Mailing Address - Phone:817-923-2101
Mailing Address - Fax:817-926-1471
Practice Address - Street 1:1401 W MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4250
Practice Address - Country:US
Practice Address - Phone:817-923-2101
Practice Address - Fax:817-926-1471
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1673222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist