Provider Demographics
NPI:1932106408
Name:CLARK, ROBERT HENRY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:HENRY
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 1:1259 WANTAGH AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-2205
Mailing Address - Country:US
Mailing Address - Phone:516-221-7971
Mailing Address - Fax:516-221-8117
Practice Address - Street 1:1259 WANTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-2205
Practice Address - Country:US
Practice Address - Phone:516-221-7971
Practice Address - Fax:516-221-8117
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144682207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01565177Medicaid
60D453Medicare PIN
NY01565177Medicaid