Provider Demographics
NPI:1700885415
Name:TERRELL, CLARK DON (MD)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:DON
Last Name:TERRELL
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 1:11124 WURZBACH RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-2438
Mailing Address - Country:US
Mailing Address - Phone:210-696-0076
Mailing Address - Fax:210-697-7207
Practice Address - Street 1:11124 WURZBACH RD
Practice Address - Street 2:STE 206
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-2445
Practice Address - Country:US
Practice Address - Phone:210-696-0076
Practice Address - Fax:210-697-7207
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG89872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0079BPMedicare ID - Type Unspecified
C22549Medicare UPIN