Provider Demographics
NPI:1962449728
Name:CLOGSTON, CHARLES W (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:CLOGSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:10100 KANIS RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6202
Mailing Address - Country:US
Mailing Address - Phone:501-255-6000
Mailing Address - Fax:501-255-6400
Practice Address - Street 1:10100 KANIS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6202
Practice Address - Country:US
Practice Address - Phone:501-255-6000
Practice Address - Fax:501-255-6400
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0428207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127369001Medicaid
ARF49601Medicare UPIN
AR5J690Medicare PIN
AR127369001Medicaid