Provider Demographics
NPI:1043272388
Name:CLARKE, GARY L (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:CLARKE
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 1:308 SILVER BRIDGE PLZ
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1833
Mailing Address - Country:US
Mailing Address - Phone:740-446-2525
Mailing Address - Fax:740-446-4371
Practice Address - Street 1:308 SILVER BRIDGE PLZ
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1833
Practice Address - Country:US
Practice Address - Phone:740-446-2525
Practice Address - Fax:740-446-4371
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3220152W00000X
WV641-D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3110671970OtherWORKERS' COMP OH
OH9263881OtherMEDICARE PTAN
WV0150144000Medicaid
WV1010821OtherWORKERS' COMP WV
OH0345700Medicaid
OH0345700Medicaid
OH1043272388Medicare UPIN