Provider Demographics
NPI:1174902621
Name:STEVEN CLARK MD PLLC
Entity type:Organization
Organization Name:STEVEN CLARK MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-675-3659
Mailing Address - Street 1:4510 MEDICAL CENTER DRIVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-1604
Mailing Address - Country:US
Mailing Address - Phone:469-675-3659
Mailing Address - Fax:469-675-3181
Practice Address - Street 1:4510 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 305
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-1604
Practice Address - Country:US
Practice Address - Phone:469-675-3659
Practice Address - Fax:469-675-3181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3567208200000X, 2082S0105X, 2086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3560955Medicaid
TX3560955Medicaid