Provider Demographics
NPI:1568434397
Name:CLARK, CHARLES THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:THOMAS
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 PARKS HALL
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701
Mailing Address - Country:US
Mailing Address - Phone:740-593-2444
Mailing Address - Fax:740-593-0905
Practice Address - Street 1:313 PARKS HALL
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701
Practice Address - Country:US
Practice Address - Phone:740-593-2444
Practice Address - Fax:740-593-0905
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34--003631208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0542158Medicaid
OHF23043Medicare UPIN
OHCL0819622Medicare PIN