Provider Demographics
NPI:1528012382
Name:CLARK, CHARLES N JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:N
Last Name:CLARK
Suffix:JR
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:PO BOX 22206
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29413-2206
Mailing Address - Country:US
Mailing Address - Phone:843-723-3441
Mailing Address - Fax:843-805-4040
Practice Address - Street 1:125 DOUGHTY ST
Practice Address - Street 2:SUITE 420
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403
Practice Address - Country:US
Practice Address - Phone:843-723-3441
Practice Address - Fax:843-805-4040
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCTL24404207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC244042Medicaid
SCAA14661459Medicare PIN
SC244042Medicaid