Provider Demographics
NPI:1720425416
Name:CLARK, CHARLES SPURGEON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:SPURGEON
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3530 HOUMA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-4203
Mailing Address - Country:US
Mailing Address - Phone:504-264-5142
Mailing Address - Fax:504-455-2648
Practice Address - Street 1:3530 HOUMA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-4203
Practice Address - Country:US
Practice Address - Phone:504-264-5142
Practice Address - Fax:504-455-2648
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2023-08-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA338282207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09004327Medicaid