Healthcare Provider Details

I. General information

NPI: 1316184815
Provider Name (Legal Business Name): CHARLES A. CLARK, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 03/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 40TH AVE SUITE 501
PINE BLUFF AR
71603-6319
US

IV. Provider business mailing address

1609 W 40TH AVE SUITE 501
PINE BLUFF AR
71603-6319
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-3449
  • Fax: 870-535-3973
Mailing address:
  • Phone: 870-534-3449
  • Fax: 870-535-3973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES ALLAN CLARK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 870-534-3449