Provider Demographics
NPI:1336318047
Name:CLARK, ROBERT W (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W WENGER RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2754
Mailing Address - Country:US
Mailing Address - Phone:937-836-1288
Mailing Address - Fax:937-832-1251
Practice Address - Street 1:12 W WENGER RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2754
Practice Address - Country:US
Practice Address - Phone:937-836-1288
Practice Address - Fax:937-832-1251
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH917111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT47489Medicare UPIN