Individual
DR. DWAYNE CHARLES CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
723 PARK RIDGE LN, N FOND DU LAC, WI 54937-1385
(920) 926-8600
(920) 926-8650
Mailing address
420 E DIVISION ST, FOND DU LAC, WI 54935-4560
(920) 926-8340
(920) 926-8370
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
48855
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00319962
RAILROAD MEDICARE
WI
Enumeration date
01/30/2006
Last updated
10/28/2020
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