Provider Demographics
NPI:1972552065
Name:CLARK, ROBERT A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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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:352-795-3205
Practice Address - Fax:727-450-1144
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2015-10-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME00514052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC78278Medicare UPIN
FLQ0142Medicare PIN