Healthcare Provider Details

I. General information

NPI: 1003478157
Provider Name (Legal Business Name): K.Q. CLARKE, MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 8TH AVE STE 603
FORT WORTH TX
76104-4142
US

IV. Provider business mailing address

1307 8TH AVE STE 603
FORT WORTH TX
76104-4142
US

V. Phone/Fax

Practice location:
  • Phone: 817-662-7044
  • Fax: 817-438-1969
Mailing address:
  • Phone: 817-662-7044
  • Fax: 817-438-1969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: KHALILAH Q CLARKE
Title or Position: DOCTOR
Credential: MD
Phone: 817-662-7044