Basic Information
| Provider Information | |||||||||
| NPI: | 1285830174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CHANELLE | ||||||||
| MiddleName: | JACORA MATTHEWS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11511 SHADOW CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775847298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134420000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2515 BUSINESS CENTER DR | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775842294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134427200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 06/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | M6750 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 188237501 | 05 | TX | MEDICAID | 188237502 | 05 | TX | MEDICAID |