Basic Information
| Provider Information | |||||||||
| NPI: | 1316406218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | MARICE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8441 STATE HWY 47 | ||||||||
| Address2: | STE 3115 | ||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9794369703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 E 29TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778022623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9794360485 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2019 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | T4333 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.