Provider Demographics
NPI:1770689358
Name:CLARK, CHARLES B III (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:B
Last Name:CLARK
Suffix:III
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 1:6025 METROPOLITAN DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-2408
Mailing Address - Country:US
Mailing Address - Phone:409-899-4999
Mailing Address - Fax:409-899-3978
Practice Address - Street 1:6025 METROPOLITAN DR
Practice Address - Street 2:SUITE 205
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-2408
Practice Address - Country:US
Practice Address - Phone:409-899-4999
Practice Address - Fax:409-899-3978
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9396207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0981946-01Medicaid
TX359865OtherMEDICARE PTAN
TX359865OtherMEDICARE PTAN