=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063516516
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT LOUIS CLARK JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 30TH ST
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50310-5753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-699-5826
-----------------------------------------------------
Fax | 515-699-5929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8275 NW 54TH AVE
-----------------------------------------------------
City | JOHNSTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50131-2712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-276-8187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 26447
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------