Provider Demographics
NPI:1386875128
Name:CLARK, CHARLOTTE ANN (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:730 E 2ND ST
Mailing Address - Street 2:APT. 3
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-4400
Mailing Address - Country:US
Mailing Address - Phone:507-454-0903
Mailing Address - Fax:507-454-0600
Practice Address - Street 1:730 E 2ND ST
Practice Address - Street 2:APT. 3
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-4400
Practice Address - Country:US
Practice Address - Phone:507-454-0903
Practice Address - Fax:507-454-0600
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN41455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine