Provider Demographics
NPI:1811903560
Name:CLARK, ROBERT T JR (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:CLARK
Suffix:JR
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 1:715 SOUTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-9021
Mailing Address - Country:US
Mailing Address - Phone:785-209-3779
Mailing Address - Fax:785-209-3780
Practice Address - Street 1:715 SOUTHWIND DR
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-9021
Practice Address - Country:US
Practice Address - Phone:785-209-3779
Practice Address - Fax:785-209-3780
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3194207Q00000X
OK40537207Q00000X
KS04-34214207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004083830004Medicaid
TX063623501Medicaid
TX137227810Medicaid
TX0082EVOtherBLUE CROSS/BLUE SHIELD
TX0075DJOtherBLUE CROSS/BLUE SHIELD
TX063623501Medicaid
TX137227810Medicaid