Provider Demographics
NPI:1720079767
Name:CLARK, DAVID CHARLES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CHARLES
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 63112
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3112
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:1331 NORTH ELM STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-6304
Practice Address - Country:US
Practice Address - Phone:336-274-9614
Practice Address - Fax:336-482-2177
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC394052085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC18290OtherPARTNERS
NC1600796OtherUNITED HEALTHCARE
NC8922555Medicaid
NC22555OtherBLUE CROSS BLUE SHIELD
NC70507OtherMEDCOST
NC300050409OtherRAILROAD MEDICARE
VA1720079767OtherVIRGINIA MEDICAID
NC300050409OtherRAILROAD MEDICARE
NCE62659Medicare UPIN