Provider Demographics
NPI:1376778746
Name:CLARK, ROBERT T SR (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:T
Last Name:CLARK
Suffix:SR
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 1:2411 US HIGHWAY 27 S
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-4943
Mailing Address - Country:US
Mailing Address - Phone:863-382-9632
Mailing Address - Fax:863-382-9632
Practice Address - Street 1:2411 US HIGHWAY 27 S
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-4943
Practice Address - Country:US
Practice Address - Phone:863-382-9632
Practice Address - Fax:863-382-9632
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3814891-00Medicaid
FL55739OtherBC/BS
FL3814891-00Medicaid