Provider Demographics
NPI:1912158627
Name:CLARK, CHARLES LEROY III (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEROY
Last Name:CLARK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5441 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-1224
Mailing Address - Country:US
Mailing Address - Phone:325-673-9806
Mailing Address - Fax:325-673-9809
Practice Address - Street 1:5441 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606
Practice Address - Country:US
Practice Address - Phone:325-673-9806
Practice Address - Fax:325-673-9809
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119554207W00000X
TXR2830207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist