Provider Demographics
NPI:1801962923
Name:CLARK, JOHN ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:ROBERT
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:42 EAST ROWAN SUITE B
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207
Mailing Address - Country:US
Mailing Address - Phone:509-489-3879
Mailing Address - Fax:509-484-1823
Practice Address - Street 1:42 EAST ROWAN SUITE B
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207
Practice Address - Country:US
Practice Address - Phone:509-489-3879
Practice Address - Fax:509-484-1823
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00164742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0124325OtherL & I
WA1105469Medicaid
AB05254Medicare ID - Type Unspecified
A07132Medicare UPIN