Provider Demographics
NPI:1083085385
Name:KATHLEEN A. CLARK MD PA
Entity type:Organization
Organization Name:KATHLEEN A. CLARK MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-350-7311
Mailing Address - Street 1:5701 TIME SQUARE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-1178
Mailing Address - Country:US
Mailing Address - Phone:806-350-7311
Mailing Address - Fax:806-350-7361
Practice Address - Street 1:5701 TIME SQUARE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119-1178
Practice Address - Country:US
Practice Address - Phone:806-350-7311
Practice Address - Fax:806-350-7361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-13
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1083085385OtherNPI