Provider Demographics
NPI:1649680406
Name:CLARK, CHARLES AMOS (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:AMOS
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3841 GREEN HILLS VILLAGE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2691
Mailing Address - Country:US
Mailing Address - Phone:615-936-2000
Mailing Address - Fax:615-936-0605
Practice Address - Street 1:VANDERBILT UNIVERSITY DEPT OF MEDICINE
Practice Address - Street 2:D-3100, MEDICAL CENTER NORTH
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232
Practice Address - Country:US
Practice Address - Phone:615-322-0417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN56206207RH0003X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ031277Medicaid