Provider Demographics
NPI:1033372727
Name:CLARK, ROBERT EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1302 FRANKLIN AVE
Mailing Address - Street 2:SUITE 4800
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3551
Mailing Address - Country:US
Mailing Address - Phone:309-454-5900
Mailing Address - Fax:309-454-2820
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:SUITE 4800
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-454-5900
Practice Address - Fax:309-454-2820
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2013-06-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMT190170207R00000X
MO2010017443207RG0100X
IL036131371207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine