Provider Demographics
NPI:1992976542
Name:CLARK, ROGER DALE (HIS)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:CLARK
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4555 E UNIVERSITY BLVD STE C7
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-8137
Mailing Address - Country:US
Mailing Address - Phone:432-444-5200
Mailing Address - Fax:
Practice Address - Street 1:4555 E UNIVERSITY BLVD STE C7
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-8137
Practice Address - Country:US
Practice Address - Phone:432-444-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80241237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX07386906OtherDRIVERS LICENSE