Provider Demographics
NPI:1508850181
Name:CLARK, ROBERT LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEON
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 1:17058 SE 58TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-5595
Mailing Address - Country:US
Mailing Address - Phone:206-790-2397
Mailing Address - Fax:425-641-4827
Practice Address - Street 1:17058 SE 58TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-5595
Practice Address - Country:US
Practice Address - Phone:206-790-2397
Practice Address - Fax:425-641-4827
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 00030055207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1508850181Medicaid
38110OtherL&I
WA810000222OtherRR MEDICARE
WAP01365435OtherRR MEDICARE
38110OtherL&I
WA810000222OtherRR MEDICARE
WA1508850181Medicaid