Healthcare Provider Details

I. General information

NPI: 1821154667
Provider Name (Legal Business Name): ROBERT T CLARK MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7575 GRAND RIVER RD SUITE 111
BRIGHTON MI
48114-9309
US

IV. Provider business mailing address

7575 WEST GRAND RIVER SUITE 111
BRIGHTON MI
48114-9390
US

V. Phone/Fax

Practice location:
  • Phone: 810-844-7744
  • Fax: 810-844-7725
Mailing address:
  • Phone: 810-844-7744
  • Fax: 810-844-7725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301040778
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number4301040778
License Number StateMI

VIII. Authorized Official

Name: DR. ROBERT THOMAS CLARK
Title or Position: PRESIDENT
Credential: MD
Phone: 810-844-7744