Provider Demographics
NPI:1427044692
Name:CLARK, THOMAS EUGENE (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:EUGENE
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 1:1715 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NEW ULM
Mailing Address - State:MN
Mailing Address - Zip Code:56073-3751
Mailing Address - Country:US
Mailing Address - Phone:507-354-8531
Mailing Address - Fax:507-359-1124
Practice Address - Street 1:1715 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NEW ULM
Practice Address - State:MN
Practice Address - Zip Code:56073-3751
Practice Address - Country:US
Practice Address - Phone:507-354-8531
Practice Address - Fax:507-359-1124
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2902152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN241M0CLOtherBLUE CROSS/BLUE SHIELD MN
MN1034694OtherPREFERRED ONE
MN2202087OtherMEDICA
MN747652300Medicaid
MNHP38790OtherHEALTHPARTNERS
MN171829OtherUCARE
MNHP38790OtherHEALTHPARTNERS
MN747652300Medicaid
MN410001996Medicare ID - Type Unspecified