Provider Demographics
NPI:1053319673
Name:CLARK, JODI LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 VIA MESA GRANDE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-6639
Mailing Address - Country:US
Mailing Address - Phone:310-373-1624
Mailing Address - Fax:
Practice Address - Street 1:17001 HAWTHORNE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-3302
Practice Address - Country:US
Practice Address - Phone:310-370-3360
Practice Address - Fax:310-370-6227
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9934T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0099340Medicaid
CASD0099340Medicaid
U60802Medicare UPIN