Provider Demographics
NPI:1689124323
Name:CLARAC, EDWARD HARRY LEE IV
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:HARRY LEE
Last Name:CLARAC
Suffix:IV
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 1:13251 GREENSTONE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-3675
Mailing Address - Country:US
Mailing Address - Phone:210-632-8972
Mailing Address - Fax:
Practice Address - Street 1:5423 HAMILTON WOLFE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4344
Practice Address - Country:US
Practice Address - Phone:210-694-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1280560225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist