Provider Demographics
NPI:1992157697
Name:BROADWAY I-30 MEDICAL CLINIC, PLLC
Entity type:Organization
Organization Name:BROADWAY I-30 MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-803-4516
Mailing Address - Street 1:407 W INTERSTATE 30
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-5912
Mailing Address - Country:US
Mailing Address - Phone:972-240-8539
Mailing Address - Fax:972-303-1994
Practice Address - Street 1:407 W INTERSTATE 30
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-5912
Practice Address - Country:US
Practice Address - Phone:972-240-8539
Practice Address - Fax:972-303-1994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0154207Q00000X
TXL4890207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty