MEDICARE: DR. ROBERT ALEXANDER CLARK M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	G080142	CA

General Provider Information

NPI Number	:	1043232325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT ALEXANDER CLARK M.D

Provider Business Mailing Address
First Line	:	955 DEEP VALLEY DR
Second Line	:	#2950
City	:	PALOS VERDES PENINSULA
State	:	CA
Zip	:	90274-3058
Country	:	US
Telephone Number	:	310-707-8113
Fax Number	:	562-595-7639

Provider Business Practice Location Address
First Line	:	4401 ATLANTIC AVE STE 410
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-2263
Country	:	US
Telephone Number	:	562-459-3363
Fax Number	:	562-459-3364

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	07/29/2022

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