Provider Demographics
NPI:1184793150
Name:CHILDERS, CLARK EDWIN JR (MD)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:EDWIN
Last Name:CHILDERS
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:4607 MACCORKLE AVE SW
Mailing Address - Street 2:MP STE 204
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1364
Mailing Address - Country:US
Mailing Address - Phone:304-767-7930
Mailing Address - Fax:304-767-7935
Practice Address - Street 1:4607 MACCORKLE AVE SW
Practice Address - Street 2:MP STE 204
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-767-7930
Practice Address - Fax:304-767-7935
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
WV18115208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0109655000Medicaid