Provider Demographics
NPI:1386675890
Name:CLARK, ROBERT MILTON (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MILTON
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
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 2510
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-2510
Mailing Address - Country:US
Mailing Address - Phone:706-922-8274
Mailing Address - Fax:706-922-6695
Practice Address - Street 1:1701 MAGNOLIA WAY STE 101
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9484
Practice Address - Country:US
Practice Address - Phone:706-922-6600
Practice Address - Fax:706-650-0239
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040887207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACH0654OtherRR MEDICARE GROUP PIN
GA040887OtherLICENSE
SCG25973Medicaid
GA00680061AMedicaid
GA336952OtherWELLCARE
GA10057091OtherAMERIGROUP
GA336952OtherWELLCARE