Provider Demographics
NPI:1083652978
Name:CLARKSON OPTOMETRY MIDWEST INC.
Entity Type:Organization
Organization Name:CLARKSON OPTOMETRY MIDWEST INC.
Other - Org Name:20/20 EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WACHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-200-4393
Mailing Address - Street 1:PO BOX 207170
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7156
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:1709 N DIXIE AVE STE 101
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9496
Practice Address - Country:US
Practice Address - Phone:636-200-4393
Practice Address - Fax:502-736-4490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77903961Medicaid
KY77903961Medicaid
KY9590Medicare PIN