Provider Demographics
NPI:1265461594
Name:CLARK, CHRISTOPHER INMAN (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:INMAN
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 1:100 4TH AVE N
Mailing Address - Street 2:SUITE 145
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-4905
Mailing Address - Country:US
Mailing Address - Phone:206-728-7505
Mailing Address - Fax:
Practice Address - Street 1:100 4TH AVE N
Practice Address - Street 2:SUITE 145
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4905
Practice Address - Country:US
Practice Address - Phone:206-728-7505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003035TX152W00000X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACL4555OtherREGENCE WA HEALTH
WA143253OtherWA DEPT OF LABOR & INDUST
WAU42395Medicare UPIN
WA143253OtherWA DEPT OF LABOR & INDUST