Healthcare Provider Details

I. General information

NPI: 1538123518
Provider Name (Legal Business Name): ROBERT B CLARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S SHACKLEFORD RD
LITTLE ROCK AR
72211-4335
US

IV. Provider business mailing address

PO BOX 65978
CHARLOTTE NC
28265-0978
US

V. Phone/Fax

Practice location:
  • Phone: 501-219-7481
  • Fax:
Mailing address:
  • Phone: 501-771-4693
  • Fax: 501-771-4885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC5383
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: