Provider Demographics
NPI:1679678270
Name:CARTER, CLINTON JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:JOHN
Last Name:CARTER
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:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-593-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3958207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184728701Medicaid
TX750818167022OtherTRICARE
TX8EX119OtherBCBS
TX106454512Medicaid
TX75-2616977-002OtherTRICARE
TX75-0818167-022OtherTRICARE
TX75-2616977-001OtherTRICARE
TX8X8162OtherBCBS
TX75-0818167-048OtherTRICARE
TX75-2616977-028OtherTRICARE
TXP01490696OtherRAIL ROAD
TX0076PAOtherBCBS
TX75-0818167-022OtherTRICARE
TX750818167022OtherTRICARE
TX75-0818167-048OtherTRICARE
TX612727Medicare PIN