Provider Demographics
NPI:1003044355
Name:LILES, CLEMIT W III (OD)
Entity Type:Individual
Prefix:DR
First Name:CLEMIT
Middle Name:W
Last Name:LILES
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:CLEMIT
Other - Middle Name:W
Other - Last Name:LILES
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:17569 FISHTRAP RD STE 30
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-5122
Mailing Address - Country:US
Mailing Address - Phone:469-715-0775
Mailing Address - Fax:
Practice Address - Street 1:2425 S ZERO ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-8663
Practice Address - Country:US
Practice Address - Phone:479-763-1230
Practice Address - Fax:479-777-4614
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2626152W00000X
TX9619T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist