Provider Demographics
NPI:1992733802
Name:CLARK, GEORGE EDWARD III (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:EDWARD
Last Name:CLARK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3150 CLARKSVILLE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-8076
Mailing Address - Country:US
Mailing Address - Phone:903-782-9206
Mailing Address - Fax:903-783-7352
Practice Address - Street 1:3150 CLARKSVILLE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-8076
Practice Address - Country:US
Practice Address - Phone:903-782-9206
Practice Address - Fax:903-783-7352
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-01-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXE6284208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124603503Medicaid
TX124603503Medicaid
TX81342GMedicare ID - Type Unspecified