Provider Demographics
NPI:1518545961
Name:GRAVELL, CLARK (MD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:GRAVELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 FRONTIER TRL STE 110
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1567
Mailing Address - Country:US
Mailing Address - Phone:512-968-3125
Mailing Address - Fax:
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-3555
Practice Address - Fax:210-702-4239
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXV5269207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program