MEDICARE: ROY ADRIAN 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	208000000X	Pediatrics Physician	L4305	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194717322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROY ADRIAN CLARKE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 961205
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76161-1205
Country	:	US
Telephone Number	:	817-740-8450
Fax Number	:

Provider Business Practice Location Address
First Line	:	7777 FOREST LN STE B300
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-2571
Country	:	US
Telephone Number	:	972-284-7770
Fax Number	:	972-284-7780

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	03/12/2020

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