Provider Demographics
NPI:1629077987
Name:CLARK, CARY BYRON (MD)
Entity Type:Individual
Prefix:DR
First Name:CARY
Middle Name:BYRON
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:10901 BAKERS CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:BLUFF DALE
Mailing Address - State:TX
Mailing Address - Zip Code:76433-5111
Mailing Address - Country:US
Mailing Address - Phone:254-823-6866
Mailing Address - Fax:
Practice Address - Street 1:10901 BAKERS CROSSING RD
Practice Address - Street 2:
Practice Address - City:BLUFF DALE
Practice Address - State:TX
Practice Address - Zip Code:76433-5111
Practice Address - Country:US
Practice Address - Phone:254-823-6866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3231207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC14508Medicare UPIN