Provider Demographics
NPI:1033372727
Name:CLARK, ROBERT EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1228 TOWANDA AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3469
Mailing Address - Country:US
Mailing Address - Phone:309-454-5900
Mailing Address - Fax:309-454-2820
Practice Address - Street 1:1228 TOWANDA AVE STE 1
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3469
Practice Address - Country:US
Practice Address - Phone:309-454-5900
Practice Address - Fax:309-454-2820
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT190170207R00000X
MO2010017443207RG0100X
IL036131371207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine