Healthcare Provider Details

I. General information

NPI: 1295494961
Provider Name (Legal Business Name): ROBERT A CLARK MD MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 ATLANTIC AVE STE 410
LONG BEACH CA
90807-2263
US

IV. Provider business mailing address

955 DEEP VALLEY DR #2950
PALOS VERDES PENINSULA CA
90274-3058
US

V. Phone/Fax

Practice location:
  • Phone: 562-459-3363
  • Fax: 562-459-3364
Mailing address:
  • Phone: 310-707-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT ALEXANDER CLARK
Title or Position: PRESIDENT
Credential: MD
Phone: 562-426-3925