Provider Demographics
NPI:1376112797
Name:CLARK, TESSA J (OD)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:2861 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9172
Mailing Address - Country:US
Mailing Address - Phone:843-725-0064
Mailing Address - Fax:843-569-7885
Practice Address - Street 1:1101 CLARITY RD STE 100
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3138
Practice Address - Country:US
Practice Address - Phone:843-881-3937
Practice Address - Fax:843-375-1487
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC2280152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist