Provider Demographics
NPI:1457300469
Name:ROBERT CLARK MD PA
Entity Type:Organization
Organization Name:ROBERT CLARK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-585-7020
Mailing Address - Street 1:2810 W SAINT ISABEL ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6375
Mailing Address - Country:US
Mailing Address - Phone:813-890-8004
Mailing Address - Fax:727-518-0762
Practice Address - Street 1:6201 N SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-6712
Practice Address - Country:US
Practice Address - Phone:727-585-7020
Practice Address - Fax:727-450-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00514052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC78278Medicare UPIN