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General NPI Number Information
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NPI Number | 1073615571
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Entity Type | Individual
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Provider Name | CLARK RED GREGG MD
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Gender | Male
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Dates
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Enumeration Date | 09/04/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4500 S LANCASTER RD
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City | DALLAS
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State | TX
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Zip | 75216-7167
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Country | US
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Telephone | 214-857-1150
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Fax |
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Provider Business Mailing Address
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Address Line | 3 WESTOVER RD
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City | FORT WORTH
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State | TX
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Zip | 76107-3104
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Country | US
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Telephone | 817-737-3435
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Fax | 817-737-6844
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | E1598
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License Number State | TX
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