Provider Demographics
NPI:1306807268
Name:CLARK, WILLIAM D (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:D
Last Name:CLARK
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 1:333 N SANTA ROSA STREET
Mailing Address - Street 2:GOLDSBURY CENTER LOWER LEVEL
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3108
Mailing Address - Country:US
Mailing Address - Phone:210-704-2335
Mailing Address - Fax:210-704-4723
Practice Address - Street 1:333 N SANTA ROSA STREET
Practice Address - Street 2:GOLDSBURY CENTER LOWER LEVEL
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3108
Practice Address - Country:US
Practice Address - Phone:210-704-2335
Practice Address - Fax:210-704-2335
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD6986207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115705908Medicaid
TX115705908Medicaid