Provider Demographics
NPI:1205830767
Name:CLARK, BOYD A (OD)
Entity Type:Individual
Prefix:DR
First Name:BOYD
Middle Name:A
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 1:725 N TYNDALL PKWY
Mailing Address - Street 2:C/O VISION CENTER
Mailing Address - City:CALLAWAY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-3219
Mailing Address - Country:US
Mailing Address - Phone:850-785-0007
Mailing Address - Fax:850-785-0009
Practice Address - Street 1:725 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:CALLAWAY
Practice Address - State:FL
Practice Address - Zip Code:32404-3219
Practice Address - Country:US
Practice Address - Phone:850-785-0007
Practice Address - Fax:850-785-0009
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL 1463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT85219Medicare UPIN
FLT85219Medicare UPIN