Provider Demographics
NPI:1336357045
Name:CLARK, ROBERT JEFF (BS, CNIM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JEFF
Last Name:CLARK
Suffix:
Gender:M
Credentials:BS, CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14983 BOAZ LN
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-4801
Mailing Address - Country:US
Mailing Address - Phone:972-786-6167
Mailing Address - Fax:903-882-7748
Practice Address - Street 1:14983 BOAZ LN
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-4801
Practice Address - Country:US
Practice Address - Phone:972-786-6167
Practice Address - Fax:903-882-7748
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic