Provider Demographics
NPI:1376700658
Name:CLARK, CHRISTOPHER ANDERSON (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:ANDERSON
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 1:800 E ATWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-3635
Mailing Address - Country:US
Mailing Address - Phone:812-855-4093
Mailing Address - Fax:812-855-5417
Practice Address - Street 1:800 E ATWATER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3635
Practice Address - Country:US
Practice Address - Phone:812-855-4093
Practice Address - Fax:812-855-5417
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003369A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200926550Medicaid
IN546000JJJJMedicare PIN
IN544150IIIIMedicare PIN