Provider Demographics
NPI:1134111511
Name:CLARK, DOUGLAS CURTIS (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:CURTIS
Last Name:CLARK
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 1:2617 HIGHWAY 31 S
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-1322
Mailing Address - Country:US
Mailing Address - Phone:205-664-1575
Mailing Address - Fax:205-664-1578
Practice Address - Street 1:2617 HIGHWAY 31 S
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-1322
Practice Address - Country:US
Practice Address - Phone:205-664-1575
Practice Address - Fax:205-664-1578
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-502-TA-105152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT69158OtherUNITED HEALTHCARE
ALT69158OtherHEALTHSPRING
AL009933955Medicaid
AL51505623OtherBLUE CROSS BLUE SHIELD
AL4795640001Medicare NSC
ALT69158Medicare UPIN
AL051505623CLAMedicare ID - Type Unspecified
AL051505623Medicare PIN