Provider Demographics
NPI:1174785042
Name:C CLARKE II MD GYN PA
Entity type:Organization
Organization Name:C CLARKE II MD GYN PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:214-316-0913
Mailing Address - Street 1:3308 PRESTON RD
Mailing Address - Street 2:STE 350, PMB 110
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7453
Mailing Address - Country:US
Mailing Address - Phone:972-303-2222
Mailing Address - Fax:972-303-2220
Practice Address - Street 1:407 W I 30
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-5912
Practice Address - Country:US
Practice Address - Phone:972-303-2222
Practice Address - Fax:972-303-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4890261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1529026-01Medicaid
TX00548HOtherOB/GYN SPECIALTY
TX00548HOtherOB/GYN SPECIALTY