Provider Demographics
NPI:1689713018
Name:CLARK, CHARLES E (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:E
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:3111 GUNDERSEN DR
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8447
Practice Address - Country:US
Practice Address - Phone:608-775-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96180207Q00000X
WI51554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ4886Medicaid
$$$$$$$$$PMedicare PIN
NMQ4886Medicaid