MEDICARE: ROBERT G. 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	207Q00000X	Family Medicine Physician	C22168	CA

General Provider Information

NPI Number	:	1174511489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT G. CLARK M.D.

Provider Business Mailing Address
First Line	:	2160 APPIAN WAY
Second Line	:	SUITE 200
City	:	PINOLE
State	:	CA
Zip	:	94564-2524
Country	:	US
Telephone Number	:	510-724-9110
Fax Number	:	916-239-3602

Provider Business Practice Location Address
First Line	:	2089 VALE RD
Second Line	:	SUITE 17
City	:	SAN PABLO
State	:	CA
Zip	:	94806-3847
Country	:	US
Telephone Number	:	510-237-2802
Fax Number	:	916-239-3612

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

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	08/05/2008

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