Provider Demographics
NPI:1740232156
Name:CLARK, RUSSELL J (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:TWO ST. MARK'S PLACE
Mailing Address - Street 2:STE 110
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945
Mailing Address - Country:US
Mailing Address - Phone:979-242-2387
Mailing Address - Fax:979-242-2206
Practice Address - Street 1:TWO ST. MARK'S PLACE
Practice Address - Street 2:STE 110
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945
Practice Address - Country:US
Practice Address - Phone:979-242-2387
Practice Address - Fax:979-242-2206
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-01-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXL8016174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8EH759OtherBCBS OF TX
TX191836903Medicaid
TX8W0858OtherBC/BS OF TEXAS
TX8G8425Medicare PIN