Provider Demographics
NPI:1104988955
Name:CLARKE, GERALD P (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:P
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 FAR WEST BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3167
Mailing Address - Country:US
Mailing Address - Phone:512-427-1100
Mailing Address - Fax:512-427-1207
Practice Address - Street 1:3410 FAR WEST BLVD STE 140
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3167
Practice Address - Country:US
Practice Address - Phone:512-427-1100
Practice Address - Fax:512-427-1207
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU9495207W00000X
WI21638-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30380600Medicaid
WI000126053Medicare PIN
WI30380600Medicaid
WICS8378Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WI000140230Medicare PIN
WI000171505Medicare PIN