MEDICARE: DR. TERRY L 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
1	2083X0100X	Occupational Medicine Physician	R-3194	AR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	080101199	OTHER		RR MEDICARE

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	:	1184654774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRY L CLARK MD

Provider Business Mailing Address
First Line	:	PO BOX 3528
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72913-3528
Country	:	US
Telephone Number	:	479-274-2000
Fax Number	:	479-274-2194

Provider Business Practice Location Address
First Line	:	4300 REGIONS PARK DR
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72916-9373
Country	:	US
Telephone Number	:	479-274-6300
Fax Number	:	479-484-4715

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	08/28/2015

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