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General NPI Number Information
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NPI Number | 1386648087
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Entity Type | Individual
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Provider Name | ROBERT THOMAS CLARK M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/09/2005
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Last Update Date | 07/16/2008
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Provider Practice Location Address
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Address Line | 7575 GRAND RIVER RD STE 111
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City | BRIGHTON
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State | MI
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Zip | 48114-9390
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Country | US
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Telephone | 810-844-7744
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Fax | 810-844-7725
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Provider Business Mailing Address
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Address Line | 1252 HIDDEN LAKE DR
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City | BLOOMFIELD
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State | MI
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Zip | 48302-1955
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Country | US
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Telephone | 248-258-1967
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Fax | 248-258-5868
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 4301040778
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4301040778
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License Number State | MI
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