Provider Demographics
NPI:1376530600
Name:CLARK, ROBERT KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KENNETH
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5849
Mailing Address - Country:US
Mailing Address - Phone:405-735-3041
Mailing Address - Fax:405-735-3146
Practice Address - Street 1:11317 S WESTERN AVE
Practice Address - Street 2:900
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-5849
Practice Address - Country:US
Practice Address - Phone:405-691-8855
Practice Address - Fax:405-691-8891
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13610174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100060770BMedicaid
OKD34504Medicare UPIN