Provider Demographics
NPI:1790938306
Name:CHARK, DAVIN WILSON (MD)
Entity Type:Individual
Prefix:
First Name:DAVIN
Middle Name:WILSON
Last Name:CHARK
Suffix:
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 1:12151 BAYPORT ST
Mailing Address - Street 2:APT.# 10-208
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4471
Mailing Address - Country:US
Mailing Address - Phone:615-243-7926
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:BLDG 56, STE 500
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-5753
Practice Address - Fax:714-456-5747
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program