Provider Demographics
NPI:1407840945
Name:CLARK, CRAIG CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:CHARLES
Last Name:CLARK
Suffix:
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 1:3650 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1710
Mailing Address - Country:US
Mailing Address - Phone:703-391-2020
Mailing Address - Fax:703-391-1211
Practice Address - Street 1:3650 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 400
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1710
Practice Address - Country:US
Practice Address - Phone:703-391-2020
Practice Address - Fax:703-391-1211
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA05622514Medicaid
VA00A410F32Medicare ID - Type Unspecified
C88908Medicare UPIN