MEDICARE: CLARK DON TERRELL 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	2084P0800X	Psychiatry Physician	G8987	TX

General Provider Information

NPI Number	:	1700885415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARK DON TERRELL MD

Provider Business Mailing Address
First Line	:	11124 WURZBACH RD
Second Line	:	SUITE 206
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-2438
Country	:	US
Telephone Number	:	210-696-0076
Fax Number	:	210-697-7207

Provider Business Practice Location Address
First Line	:	11124 WURZBACH RD
Second Line	:	STE 206
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-2445
Country	:	US
Telephone Number	:	210-696-0076
Fax Number	:	210-697-7207

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	07/12/2007

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