MEDICARE: DR. GORDON MICHAEL CLARK SR. 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	207R00000X	Internal Medicine Physician	H6794	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	:	1629116744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON MICHAEL CLARK SR. M.D.

Provider Business Mailing Address
First Line	:	4119 EMERSON AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-1144
Country	:	US
Telephone Number	:	214-520-0720
Fax Number	:	214-520-0720

Provider Business Practice Location Address
First Line	:	4119 EMERSON AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-1144
Country	:	US
Telephone Number	:	214-520-0720
Fax Number	:	214-520-0720

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

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	07/08/2007

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