Healthcare Provider Details

I. General information

NPI: 1093977449
Provider Name (Legal Business Name): KHALILAH Q CLARKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W 7TH ST STE A
FORT WORTH TX
76107-2569
US

IV. Provider business mailing address

3600 W 7TH ST STE A
FORT WORTH TX
76107-2569
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 NumberP4038
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: