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General NPI Number Information
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NPI Number | 1992157697
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Entity Type | Organization
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Legal Business Name | BROADWAY I-30 MEDICAL CLINIC, PLLC
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Dates
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Enumeration Date | 07/06/2016
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Last Update Date | 07/06/2016
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Provider Practice Location Address
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Address Line | 407 W INTERSTATE 30
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City | GARLAND
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State | TX
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Zip | 75043-5912
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Country | US
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Telephone | 972-240-8539
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Fax | 972-303-1994
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Provider Business Mailing Address
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Address Line | 407 W INTERSTATE 30
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City | GARLAND
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State | TX
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Zip | 75043-5912
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Country | US
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Telephone | 972-240-8539
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Fax | 972-303-1994
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Authorized Official
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Title or Position | MEDICAL DIRECTOR-OWNER
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Name | CARLTON K CLARKE
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Credential | MD
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Telephone | 214-803-4516
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | F0154
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | L4890
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License Number State | TX
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