Healthcare Provider Details

I. General information

NPI: 1528329562
Provider Name (Legal Business Name): AUSTRALIA D CLARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 INTERSTATE 45 N STE 100
CONROE TX
77304-5076
US

IV. Provider business mailing address

4015 INTERSTATE 45 N STE 100
CONROE TX
77304-5076
US

V. Phone/Fax

Practice location:
  • Phone: 936-270-4600
  • Fax: 936-856-8429
Mailing address:
  • Phone: 936-270-4600
  • Fax: 936-856-8429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberQ1805
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: