Provider Demographics
NPI:1043205461
Name:CLARK, CHARLES A (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1609 W 40TH AVE
Mailing Address - Street 2:STE 501
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6329
Mailing Address - Country:US
Mailing Address - Phone:870-534-3449
Mailing Address - Fax:870-535-6730
Practice Address - Street 1:1609 W 40TH AVE
Practice Address - Street 2:STE 501
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6329
Practice Address - Country:US
Practice Address - Phone:870-534-3449
Practice Address - Fax:870-535-6730
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARN8106207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119794001Medicaid
ARE93217Medicare UPIN
AR119794001Medicaid