Healthcare Provider Details

I. General information

NPI: 1902826498
Provider Name (Legal Business Name): ROBIN D CLARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11370 ANDERSON ST STE B-100
LOMA LINDA CA
92354-3450
US

IV. Provider business mailing address

5701 FILE NUMBER
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2848
  • Fax:
Mailing address:
  • Phone: 909-558-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberG44702
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG44702
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: