Provider Demographics
NPI:1356333413
Name:CLARKSON, ZACK C (OD)
Entity Type:Individual
Prefix:
First Name:ZACK
Middle Name:C
Last Name:CLARKSON
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 1:1513 GREGG ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3529
Mailing Address - Country:US
Mailing Address - Phone:803-254-4951
Mailing Address - Fax:803-254-4952
Practice Address - Street 1:1513 GREGG ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3529
Practice Address - Country:US
Practice Address - Phone:803-254-4951
Practice Address - Fax:803-254-4952
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
407540233OtherRAILROAD MEDICARE
SCD05340Medicaid
047383001OtherDMERC
SC8567Medicare PIN
407540233OtherRAILROAD MEDICARE