Provider Demographics
NPI:1982600789
Name:CLARK, ROBERT EARL (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EARL
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WELLESLEY TRADE LN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-5576
Mailing Address - Country:US
Mailing Address - Phone:919-363-7546
Mailing Address - Fax:919-363-3616
Practice Address - Street 1:200 WELLESLEY TRADE LN
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-5576
Practice Address - Country:US
Practice Address - Phone:919-363-7546
Practice Address - Fax:919-363-3616
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31121207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC562070218COtherCIGNA
NC070012681OtherRETIRED RAILROAD MEDICARE
NC9715177001OtherCIGNA HEALTHCARE
NC0354066OtherUNITED HEALTHCARE
NC8911591Medicaid
NC81690OtherMEDCOST
NC11591OtherBCBS
NC13334OtherDOCTOR'S HEALTH PLAN
NC2046860OtherAETNA HMO
NC259852OtherMAMSI
NC13123OtherPARTNERS
NC4347967OtherAETNA PPO
NC2046860OtherAETNA HMO
NC259852OtherMAMSI