Provider Demographics
NPI:1225162753
Name:CLARKE, ROBERT BROOKS (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BROOKS
Last Name:CLARKE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:520 E DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8307
Practice Address - Country:US
Practice Address - Phone:903-593-1721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTIN PLUS 028OtherTRICARE LINDALE LOCATION
TXTIN PLUS 007OtherTRICARE DOUGLAS LOCATION
TX200344401Medicaid
TXTIN PLUS 001OtherTRICARE CANTON LOCATION
TXTIN PLUS 028OtherTRICARE LINDALE LOCATION
TXS56239Medicare UPIN
TX200344401Medicaid
TX8L4462Medicare Oscar/Certification
TX970019143Medicare PIN