MEDICARE: DR. GARY R CLARK D.O.

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	207P00000X	Emergency Medicine Physician	L8651	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	T0134490	OTHER	TX	CONTROLLED SUBSTANCE

General Provider Information

NPI Number	:	1174563803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY R CLARK D.O.

Provider Business Mailing Address
First Line	:	1529 HACKETT CREEK DR
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75070-5068
Country	:	US
Telephone Number	:	972-886-5702
Fax Number	:

Provider Business Practice Location Address
First Line	:	2929 S HAMPTON RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75224-3026
Country	:	US
Telephone Number	:	214-623-4400
Fax Number	:

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	03/07/2023

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