Individual
ROBERT THOMAS CLARK
Active
Individual
ROBERT THOMAS CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
4301040778
MI
207W00000X
Ophthalmology Physician
Primary
4301040778
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1804701481
BCBS INDIV PIN
MI
05
—
2681557
—
MI
01
—
4301040778
STATE LICENSE
MI
01
—
900D710610
BCBSM OPTOMETRIC GROUP
MI
01
—
RC040778
BCBS REFERRING
MI
Enumeration date
06/09/2005
Last updated
07/16/2008
Update your record
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