Healthcare Provider Details

I. General information

NPI: 1710179684
Provider Name (Legal Business Name): ROBERT CLARK MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11401 S. WESTERN
OKLAHOMA CITY OK
73170
US

IV. Provider business mailing address

PO BOX 960313
OKLAHOMA CITY OK
73196-0001
US

V. Phone/Fax

Practice location:
  • Phone: 405-735-3041
  • Fax: 405-735-3146
Mailing address:
  • Phone: 405-951-2298
  • Fax: 405-951-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BART H DAWSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 405-951-2987