Provider Demographics
NPI:1437213907
Name:CLARK, JOHN D (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
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 1:81 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1737
Mailing Address - Country:US
Mailing Address - Phone:315-781-2650
Mailing Address - Fax:315-781-1970
Practice Address - Street 1:CLARK EYE CARE CENTER
Practice Address - Street 2:81 NORTH ST
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456
Practice Address - Country:US
Practice Address - Phone:315-781-2650
Practice Address - Fax:315-781-1970
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPC100190CSOtherPREFERRED CARE
NYPO10005491OtherBLUE CHOICE, MONROE PLAN
NYPC100190CSOtherPREFERRED CARE
NYBA0028Medicare ID - Type UnspecifiedGROUP NUMBER
NYPO10005491OtherBLUE CHOICE, MONROE PLAN