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General NPI Number Information
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NPI Number | 1780913640
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Entity Type | Individual
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Provider Name | CHARLES S CLARK
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Gender | Male
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Dates
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Enumeration Date | 12/23/2009
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Last Update Date | 12/23/2009
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Provider Practice Location Address
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Address Line | BLDG. H 2005 KNIGHT LANE ATTN: MEDICAL STAFF SERVICES NAVY MEDICINE SUPPORT COMMAND
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City | JACKSONVILLE
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State | FL
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Zip | 92055-0140
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Country | US
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Telephone | 858-361-9254
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Fax |
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Provider Business Mailing Address
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Address Line | 3986 SHIELDS ST
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City | SAN DIEGO
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State | CA
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Zip | 92124-3314
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Country | US
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Telephone | 858-361-9254
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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