Individual
ROBERT THOMAS CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
7575 GRAND RIVER RD, STE 111, BRIGHTON, MI 48114-9390
(810) 844-7744
(810) 844-7725
Mailing address
1252 HIDDEN LAKE DR, BLOOMFIELD, MI 48302-1955
(248) 258-1967
(248) 258-5868
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
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