Provider Demographics
NPI:1629174461
Name:CLARK, ROBERT DEAN (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DEAN
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 1:28 CLINTON AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:ME
Mailing Address - Zip Code:04901-7076
Mailing Address - Country:US
Mailing Address - Phone:207-873-0904
Mailing Address - Fax:207-873-0904
Practice Address - Street 1:28 CLINTON AVE STE 2
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:ME
Practice Address - Zip Code:04901-7076
Practice Address - Country:US
Practice Address - Phone:207-873-0904
Practice Address - Fax:207-873-0904
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1063111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEC0425OtherANTHEM BLUE CROSS BLUE SH
ME030231Medicare UPIN
MEMM6393Medicare ID - Type Unspecified