MEDICARE: DR. CARLTON KEITH CLARKE II 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	207V00000X	Obstetrics & Gynecology Physician	L4890	TX
2	208D00000X	General Practice Physician	L4890	TX
3	207Q00000X	Family Medicine Physician	L4890	TX
4	207QA0401X	Addiction Medicine (Family Medicine) Physician	L4890	TX
5	207QA0505X	Adult Medicine Physician	L4890	TX
6	207QG0300X	Geriatric Medicine (Family Medicine) Physician	L4890	TX
7	207R00000X	Internal Medicine Physician	L4890	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	:	1467452649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLTON KEITH CLARKE II MD

Provider Business Mailing Address
First Line	:	407 W INTERSTATE 30
Second Line	:
City	:	GARLAND
State	:	TX
Zip	:	75043-5912
Country	:	US
Telephone Number	:	972-303-2222
Fax Number	:	972-303-2220

Provider Business Practice Location Address
First Line	:	407 W I 30
Second Line	:
City	:	GARLAND
State	:	TX
Zip	:	75043-5912
Country	:	US
Telephone Number	:	972-303-2222
Fax Number	:	972-303-2220

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	02/01/2016

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