Basic Information
| Provider Information | |||||||||
| NPI: | 1184654774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3528 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729133528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792742000 | ||||||||
| FaxNumber: | 4792742194 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 REGIONS PARK DR | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729169373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792746300 | ||||||||
| FaxNumber: | 4794844715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 08/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | R-3194 | AR | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 111575001 | 05 | AR | MEDICAID | 080101199 | 01 | RR MEDICARE | OTHER |