Provider Demographics
NPI:1033220868
Name:CLARK, JOHN ALFRED (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALFRED
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 1:11225 BRONSON RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-9318
Mailing Address - Country:US
Mailing Address - Phone:352-409-5783
Mailing Address - Fax:
Practice Address - Street 1:4000 CENTRAL FLORIDA BLVD
Practice Address - Street 2:UNIVERSITY OF CENTRAL FL. - STUDENT UNION BLDG.
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32816-8005
Practice Address - Country:US
Practice Address - Phone:407-823-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA00379152W00000X
FLOP 1726152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIT 53374Medicare UPIN