Provider Demographics
NPI:1073575213
Name:CLARK, LORI J (OD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:J
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 1:1145 MANHATTAN AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5333
Mailing Address - Country:US
Mailing Address - Phone:310-546-4618
Mailing Address - Fax:310-546-9268
Practice Address - Street 1:1145 MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5333
Practice Address - Country:US
Practice Address - Phone:310-546-4618
Practice Address - Fax:310-546-9268
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP8950T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0089501Medicaid
CASD0089501Medicaid