Basic Information
| Provider Information | |||||||||
| NPI: | 1902122443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 PRESTON PARK BLVD | ||||||||
| Address2: | STE 1825 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750933656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728677862 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3901 W 15TH ST | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750757738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725966800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2010 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | Q7164 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.