Provider Demographics
NPI:1407900400
Name:CLARK, JAMES ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROBERT
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 1:325 WINDING RIVER LN STE 102
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-3589
Mailing Address - Country:US
Mailing Address - Phone:434-817-2442
Mailing Address - Fax:
Practice Address - Street 1:325 WINDING RIVER LN STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-3589
Practice Address - Country:US
Practice Address - Phone:434-817-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL155019207R00000X
VA0101050599207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA271538OtherBLUE CROSS BLUE SHIELD
VA49D0940134OtherCLIA NUMBER
VA541857642OtherTRICARE PROVIDER NUMBER
VA541857642OtherCOMMERCIAL PROVIDER #
VAG38343Medicare UPIN
VA541857642OtherTRICARE PROVIDER NUMBER