1750364188 NPI number — MR. DENNIS JAY CLARK JR. PA C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750364188 NPI number — MR. DENNIS JAY CLARK JR. PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
DENNIS
Provider Middle Name:
JAY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
PA C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750364188
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 459
Provider Second Line Business Mailing Address:
110 MAGEE STREET
Provider Business Mailing Address City Name:
GROVETON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75845-0459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-642-0841
Provider Business Mailing Address Fax Number:
936-642-0849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 MAGEE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROVETON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75845-4185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-642-0841
Provider Business Practice Location Address Fax Number:
936-642-0849
Provider Enumeration Date:
11/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA 02393 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 203876201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: PA 02393 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 203876202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com