Individual ProviderCraig Charles ClarkFamily MedicineAllopathic & Osteopathic PhysiciansPractice Address3650 Joseph Siewick Dr, Suite 400, Fairfax, VA 22033-1710(703) 391-2020PECOS EnrollmentBased on the most recent information from CMS, provider Craig Charles Clark does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records yesterday at 12:57 PM.Profile DetailsProvider ID1407840945Provider TypeIndividualFull NameClark, Craig CharlesCredentialMDGenderMaleSole ProprietorNoEnumeration Date9/9/2005Last Updated11/30/2007Contact InformationPractice LocationPractice Address3650 Joseph Siewick Dr, Suite 400, Fairfax, VA 22033-1710Phone(703) 391-2020Fax(703) 391-1211Mailing LocationMailing Address3650 Joseph Siewick Dr, Suite 400, Fairfax, VA 22033-1710Phone(703) 391-2020Fax(703) 391-1211Provider TaxonomiesCodeDescriptionLicenseCode207Q00000XPrimaryDescriptionFamily MedicineAllopathic & Osteopathic PhysiciansLicense0101037862VirginiaProvider IdentifiersIDDescriptionIssuerID05622514DescriptionMedicaidIssuerUnlistedVirginia