Provider Demographics
NPI:1275689689
Name:CLARK, ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:
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 1:644 SAN ANTONIO RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-1304
Mailing Address - Country:US
Mailing Address - Phone:650-948-3260
Mailing Address - Fax:
Practice Address - Street 1:644 SAN ANTONIO RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-1304
Practice Address - Country:US
Practice Address - Phone:650-948-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9523T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist