Provider Demographics
NPI:1205904497
Name:CLARK, ROBERT JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1568 WOOD TRL
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6066
Mailing Address - Country:US
Mailing Address - Phone:248-814-1080
Mailing Address - Fax:
Practice Address - Street 1:2861 S ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4579
Practice Address - Country:US
Practice Address - Phone:248-852-5230
Practice Address - Fax:248-852-2561
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003269152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT96953Medicare UPIN
MIN26930120Medicare PIN