Provider Demographics
NPI:1376542597
Name:CLARK, ROBERT DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DALE
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 58
Mailing Address - Street 2:
Mailing Address - City:CROSSNORE
Mailing Address - State:NC
Mailing Address - Zip Code:28616-0058
Mailing Address - Country:US
Mailing Address - Phone:828-528-1168
Mailing Address - Fax:
Practice Address - Street 1:137 NOTALEE ST
Practice Address - Street 2:
Practice Address - City:NEWLAND
Practice Address - State:NC
Practice Address - Zip Code:28657
Practice Address - Country:US
Practice Address - Phone:828-528-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0098-01210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126GUMedicaid
NC89126GUMedicaid
NCH16150Medicare UPIN