Provider Demographics
NPI:1710970785
Name:CLARK, CHARLES SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:SCOTT
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C
Other - Middle Name:SCOTT
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3390 N CAMPBELL AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2380
Mailing Address - Country:US
Mailing Address - Phone:520-795-7650
Mailing Address - Fax:520-325-1622
Practice Address - Street 1:3390 N CAMPBELL AVE
Practice Address - Street 2:STE 110
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2380
Practice Address - Country:US
Practice Address - Phone:520-795-7650
Practice Address - Fax:520-325-1622
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22462207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG06907Medicare UPIN
AZ05WCHGG74Medicare ID - Type Unspecified