Provider Demographics
NPI:1114346434
Name:CLARK, CHARLES III (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CLARK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 W JETTON AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5327
Mailing Address - Country:US
Mailing Address - Phone:813-784-0002
Mailing Address - Fax:
Practice Address - Street 1:9850 W ST LUKES DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-7912
Practice Address - Country:US
Practice Address - Phone:208-706-2663
Practice Address - Fax:208-489-4300
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-15579207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery