Provider Demographics
NPI:1144372525
Name:CLARK-NEITZEL, CHARLOTTE BARBARA (MD)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:BARBARA
Last Name:CLARK-NEITZEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 NE KRESKY AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2412
Mailing Address - Country:US
Mailing Address - Phone:360-330-9562
Mailing Address - Fax:360-330-9560
Practice Address - Street 1:3775 MARTIN WAY E
Practice Address - Street 2:SUITE A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5007
Practice Address - Country:US
Practice Address - Phone:360-236-7166
Practice Address - Fax:360-529-8070
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0029059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB23287Medicare ID - Type Unspecified
F46552Medicare UPIN
WA1093533Medicaid