MEDICARE: DR. JOHN SAMUEL CLARKE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	G9082	TX
2	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	G9082	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003811928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN SAMUEL CLARKE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 10090
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75711-0090
Country	:	US
Telephone Number	:	903-825-1981
Fax Number	:	903-825-3375

Provider Business Practice Location Address
First Line	:	119 LAKE BLUFF DR
Second Line	:
City	:	BULLARD
State	:	TX
Zip	:	75757-9740
Country	:	US
Telephone Number	:	903-825-1981
Fax Number	:	903-825-3375

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	08/12/2008

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