Provider Demographics
NPI:1457353575
Name:CLARK, JOHN ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 E CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-2041
Mailing Address - Country:US
Mailing Address - Phone:517-279-8465
Mailing Address - Fax:
Practice Address - Street 1:370 E CHICAGO ST STE 400
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2062
Practice Address - Country:US
Practice Address - Phone:517-279-8465
Practice Address - Fax:517-279-8665
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044745A207V00000X
ND6766207V00000X
MIJC062758207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3044976Medicaid
MI1607527581OtherBLUE CROSS BLUE SHIELD
MIP89384OtherBLUE CARE NETWORK
MI07-30237OtherIBA/PHP
MI07-30237OtherIBA/PHP
MIC78427Medicare UPIN