1386648087 NPI number — ROBERT THOMAS CLARK M.D.

Table of content: ROBERT THOMAS CLARK M.D. (NPI 1386648087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386648087 NPI number — ROBERT THOMAS CLARK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
ROBERT
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386648087
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/15/2006
NPI Reactivation Date:
03/28/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1252 HIDDEN LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302-1955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-258-1967
Provider Business Mailing Address Fax Number:
248-258-5868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7575 GRAND RIVER RD
Provider Second Line Business Practice Location Address:
STE 111
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48114-9390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-844-7744
Provider Business Practice Location Address Fax Number:
810-844-7725
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  4301040778 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 4301040778 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RC040778 . This is a "BCBS REFERRING" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1804701481 . This is a "BCBS INDIV PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301040778 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2681557 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900D710610 . This is a "BCBSM OPTOMETRIC GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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