Provider Demographics
NPI:1174511489
Name:CLARK, ROBERT G (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2160 APPIAN WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2524
Mailing Address - Country:US
Mailing Address - Phone:510-724-9110
Mailing Address - Fax:916-239-3602
Practice Address - Street 1:2089 VALE RD
Practice Address - Street 2:SUITE 17
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3847
Practice Address - Country:US
Practice Address - Phone:510-237-2802
Practice Address - Fax:916-239-3612
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-08-05
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Provider Licenses
StateLicense IDTaxonomies
CAC22168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA32093Medicare UPIN
CA00C221681Medicare PIN
CA00C221680Medicare PIN