Provider Demographics
NPI:1407936008
Name:DR MICHAEL CLARK OPTOMETRIST PA
Entity Type:Organization
Organization Name:DR MICHAEL CLARK OPTOMETRIST PA
Other - Org Name:MT AIRY VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-789-9031
Mailing Address - Street 1:602 S RENFRO ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-4742
Mailing Address - Country:US
Mailing Address - Phone:336-789-9031
Mailing Address - Fax:336-789-8343
Practice Address - Street 1:602 S RENFRO ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4742
Practice Address - Country:US
Practice Address - Phone:336-789-9031
Practice Address - Fax:336-789-8343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0884152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89013MWMedicaid
NC3739OtherBLUE MEDICARE HMO
1409898OtherUNITED MINE WORKERS
VA9203311OtherVIRGINIA MEDICAID
NC013MWOtherBCBS OF NC
NC580000014OtherPALMETTO GBA--RAILROAD MEDICARE
=========0002OtherCIGNA
NCT64596Medicare UPIN
NC246019Medicare PIN
VA9203311OtherVIRGINIA MEDICAID