Basic Information
| Provider Information | |||||||||
| NPI: | 1225268907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | WILLIAMS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | E. | ||||||||
| OtherMiddleName: | WILL | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | UT SOUTHWESTERN MEDICAL CTR | ||||||||
| Address2: | 5323 HARRY HINES BLVD | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753909121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146458500 | ||||||||
| FaxNumber: | 2146453775 | ||||||||
| Practice Location | |||||||||
| Address1: | UT SOUTHWESTERN MEDICAL CTR | ||||||||
| Address2: | 5323 HARRY HINES BLVD | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753909121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146458500 | ||||||||
| FaxNumber: | 2146453775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2009 | ||||||||
| LastUpdateDate: | 05/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | P0026 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.