MEDICARE: DR. CLARK WESLEY BRAZIL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	E1512	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073595708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLARK WESLEY BRAZIL MD

Provider Business Mailing Address
First Line	:	1508 10TH ST
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76301-4401
Country	:	US
Telephone Number	:	940-322-6671
Fax Number	:	940-322-6676

Provider Business Practice Location Address
First Line	:	1508 10TH ST
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76301-4401
Country	:	US
Telephone Number	:	940-322-6671
Fax Number	:	940-322-6676

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2005
Last Update Date	:	04/12/2013

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