MEDICARE: DR. JOHN ROBERT 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	207V00000X	Obstetrics & Gynecology Physician	01044745A	IN
2	207V00000X	Obstetrics & Gynecology Physician	6766	ND
3	207V00000X	Obstetrics & Gynecology Physician	JC062758	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1607527581	OTHER	MI	BLUE CROSS BLUE SHIELD
3	P89384	OTHER	MI	BLUE CARE NETWORK
4	07-30237	OTHER	MI	IBA/PHP

General Provider Information

NPI Number	:	1457353575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ROBERT CLARK M.D.

Provider Business Mailing Address
First Line	:	274 E CHICAGO ST
Second Line	:
City	:	COLDWATER
State	:	MI
Zip	:	49036-2041
Country	:	US
Telephone Number	:	517-279-8465
Fax Number	:

Provider Business Practice Location Address
First Line	:	370 E CHICAGO ST STE 400
Second Line	:
City	:	COLDWATER
State	:	MI
Zip	:	49036-2062
Country	:	US
Telephone Number	:	517-279-8465
Fax Number	:	517-279-8665

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	08/12/2024

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Directions to “ DR. JOHN ROBERT CLARK M.D.” Practice Location

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