Provider Demographics
NPI:1386648087
Name:CLARK, ROBERT THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:THOMAS
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 1:1252 HIDDEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1955
Mailing Address - Country:US
Mailing Address - Phone:248-258-1967
Mailing Address - Fax:248-258-5868
Practice Address - Street 1:7575 GRAND RIVER RD
Practice Address - Street 2:STE 111
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9390
Practice Address - Country:US
Practice Address - Phone:810-844-7744
Practice Address - Fax:810-844-7725
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2008-07-16
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
MI4301040778207W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRC040778OtherBCBS REFERRING
MI1804701481OtherBCBS INDIV PIN
MI4301040778OtherSTATE LICENSE
MI2681557Medicaid
MI900D710610OtherBCBSM OPTOMETRIC GROUP
MI2681557Medicaid
MIA73515Medicare UPIN