Provider Demographics
NPI:1932176625
Name:CLARK, EMMETTE A (MD)
Entity Type:Individual
Prefix:DR
First Name:EMMETTE
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:E.
Other - Middle Name:A
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:460 HIDDEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-8784
Mailing Address - Country:US
Mailing Address - Phone:972-346-2300
Mailing Address - Fax:972-346-2300
Practice Address - Street 1:460 HIDDEN LAKE DR
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8784
Practice Address - Country:US
Practice Address - Phone:972-346-2300
Practice Address - Fax:972-346-2300
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AL507OtherBCBS
TX345805YMZXMedicare PIN
TX8AL507OtherBCBS
TXC14502Medicare UPIN