Provider Demographics
NPI:1629116744
Name:CLARK, GORDON MICHAEL SR (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:MICHAEL
Last Name:CLARK
Suffix:SR
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 1:4119 EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-1144
Mailing Address - Country:US
Mailing Address - Phone:214-520-0720
Mailing Address - Fax:214-520-0720
Practice Address - Street 1:4119 EMERSON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-1144
Practice Address - Country:US
Practice Address - Phone:214-520-0720
Practice Address - Fax:214-520-0720
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80W0278Medicaid
TX80W0278Medicaid
TX80W027Medicare ID - Type Unspecified