Provider Demographics
NPI:1265403265
Name:HARRIS, ROBERT CLARK (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:CLARK
Last Name:HARRIS
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:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-8642
Practice Address - Street 1:615 OLD SYMSONIA RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-5042
Practice Address - Country:US
Practice Address - Phone:270-527-4800
Practice Address - Fax:270-527-4910
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20594207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64205941Medicaid
KY64205941Medicaid
KY0933223Medicare PIN
KY0935604Medicare PIN
KYB04823Medicare UPIN