Provider Demographics
NPI:1265669170
Name:LINDA J. CLARK, O.D.
Entity Type:Organization
Organization Name:LINDA J. CLARK, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-533-4910
Mailing Address - Street 1:1765 STAFFORD CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6542
Mailing Address - Country:US
Mailing Address - Phone:574-533-4910
Mailing Address - Fax:574-534-3479
Practice Address - Street 1:1765 STAFFORD CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6542
Practice Address - Country:US
Practice Address - Phone:574-533-4910
Practice Address - Fax:574-534-3479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0301900001Medicare NSC