Provider Demographics
NPI:1124214051
Name:CLARKSON OPTOMETRY ILLINOIS PC
Entity Type:Organization
Organization Name:CLARKSON OPTOMETRY ILLINOIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:WACHTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:636-200-4393
Mailing Address - Street 1:PO BOX 207163
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7154
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:2525 GREEN MOUNT CROSSING DR.
Practice Address - Street 2:SUITE 290
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-6735
Practice Address - Country:US
Practice Address - Phone:636-200-4393
Practice Address - Fax:618-233-7290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0046.009944152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210906Medicare PIN
0360070029Medicare NSC