Provider Demographics
NPI:1184695975
Name:CLARK, DWAYNE CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:CHARLES
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:723 PARK RIDGE LN
Practice Address - Street 2:
Practice Address - City:N FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-1385
Practice Address - Country:US
Practice Address - Phone:920-926-8600
Practice Address - Fax:920-926-8650
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2020-10-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI48855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00319962OtherRAILROAD MEDICARE
WIP00319962OtherRAILROAD MEDICARE