Provider Demographics
NPI:1164686572
Name:CLARK, BRIAN M (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
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 1:7635 SHELBYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5409
Mailing Address - Country:US
Mailing Address - Phone:502-423-8500
Mailing Address - Fax:502-339-0571
Practice Address - Street 1:7635 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5409
Practice Address - Country:US
Practice Address - Phone:502-423-8500
Practice Address - Fax:502-339-0571
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1742DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00850448OtherRR MEDICARE
KY7100113750Medicaid
0191960001Medicare NSC
9010610Medicare PIN