Provider Demographics
NPI:1518103886
Name:CLARK, KATHLEEN ANNE (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 TIME SQUARE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-1178
Mailing Address - Country:US
Mailing Address - Phone:806-350-7311
Mailing Address - Fax:806-350-7361
Practice Address - Street 1:5701 TIME SQUARE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119-1178
Practice Address - Country:US
Practice Address - Phone:806-350-7311
Practice Address - Fax:806-350-7361
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX42540207R00000X, 207V00000X
NY251181-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200232280 AMedicaid
TX8L8001OtherMEDICARE
NM83982876Medicaid
TX8L20138OtherMEDICARE - OB/GYN
TX199457601Medicaid
TX199457602OtherMEDICAID - OB/GYN