| Doctor Name: | MARY CLARK |
| NPI Number: | 1104174846 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | M.D. |
| License Number: | 27610 |
| Business Practice Address: | 3551 Roger Brooke Dr Dpals Jbsa Ft Sam Houston, TX - 782344504 |
| Business Phone Number: | 5087768014 |
| Business Fax Number: | |
| Mailing Address: | 3551 Roger Brooke Dr, Dpals JBSA FT SAM HOUSTON |
| State: | TX |
| Postal Code: | 782344504 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 08/28/2012 |
| NPI Last Update Date: | 09/23/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 27610 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NE |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |