Provider Demographics
NPI:1205820081
Name:CLARK, DARYLE L (OD)
Entity Type:Individual
Prefix:DR
First Name:DARYLE
Middle Name:L
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 1:312 E LAKEWAY RD
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6329
Mailing Address - Country:US
Mailing Address - Phone:307-686-2010
Mailing Address - Fax:307-686-1052
Practice Address - Street 1:312 E LAKEWAY RD
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6329
Practice Address - Country:US
Practice Address - Phone:307-687-7353
Practice Address - Fax:307-686-1052
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2015-12-05
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
WY191T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104289100Medicaid
WY104289100Medicaid