Provider Demographics
NPI:1003862210
Name:CLARK, ANTHONY RONALD (OD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RONALD
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216E NC HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-2208
Mailing Address - Country:US
Mailing Address - Phone:919-544-2020
Mailing Address - Fax:919-433-0298
Practice Address - Street 1:2216 E NC HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-2208
Practice Address - Country:US
Practice Address - Phone:919-544-2020
Practice Address - Fax:919-433-0298
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1360152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U05971Medicare UPIN
2467209AMedicare PIN
NC0777330001Medicare NSC
NC890913FMedicaid