Provider Demographics
NPI:1780913640
Name:CLARK, CHARLES S
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3986 SHIELDS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3314
Mailing Address - Country:US
Mailing Address - Phone:858-361-9254
Mailing Address - Fax:
Practice Address - Street 1:BLDG. H 2005 KNIGHT LANE ATTN: MEDICAL STAFF SERVICES
Practice Address - Street 2:NAVY MEDICINE SUPPORT COMMAND
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:92055-0140
Practice Address - Country:US
Practice Address - Phone:858-361-9254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical