Provider Demographics
NPI:1265480602
Name:CLARK, ROBERT EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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 780
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93232-0780
Mailing Address - Country:US
Mailing Address - Phone:415-272-3517
Mailing Address - Fax:
Practice Address - Street 1:1141 ROSE AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3241
Practice Address - Country:US
Practice Address - Phone:559-891-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29418174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C294180Medicaid
300062393OtherRAILROAD MEDICARE PIN
CABC479QMedicare PIN
CAA33918Medicare UPIN
CABC479PMedicare PIN
CA00C294180Medicaid
CABC4790Medicare PIN