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NPI Code Detail

MEDICARE: ALAN S CLARK MD

MEDICARE: ALAN S CLARK MD
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
1207P00000XEmergency Medicine PhysicianK5489TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
10002KLOTHERTXBCBS

General Provider Information

NPI Number : 1053351254
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALAN S CLARK MD
Provider Business Mailing Address
First Line : PO BOX 8549
Second Line :
City : FORT WORTH
State : TX
Zip : 76124-0549
Country : US
Telephone Number : 817-451-4208
Fax Number : 817-563-3699
Provider Business Practice Location Address
First Line : 1612 S HENDERSON BLVD
Second Line :
City : KILGORE
State : TX
Zip : 75662-3518
Country : US
Telephone Number : 903-984-3505
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/07/2006
Last Update Date : 02/05/2008

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