Provider Demographics
NPI:1790828648
Name:WILLIAM CLARK MEDICAL GROUP PA
Entity Type:Organization
Organization Name:WILLIAM CLARK MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-272-0888
Mailing Address - Street 1:PO BOX 670188
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77267-0188
Mailing Address - Country:US
Mailing Address - Phone:281-272-0888
Mailing Address - Fax:281-272-0895
Practice Address - Street 1:133 NORTHPOINT DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-3207
Practice Address - Country:US
Practice Address - Phone:281-272-0888
Practice Address - Fax:713-695-7765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4818208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1760445704Medicaid
TX130727402Medicaid
TX130727403Medicaid
TX1790828648Medicaid
TX083833601Medicaid
TX1760445704Medicaid