Provider Demographics
NPI:1437446440
Name:CLARK, SHANE ALEXANDER (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ALEXANDER
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3027 ROXBURY CIR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-5301
Mailing Address - Country:US
Mailing Address - Phone:816-853-9407
Mailing Address - Fax:605-342-0209
Practice Address - Street 1:5734 SHERIDAN LAKE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8811
Practice Address - Country:US
Practice Address - Phone:605-342-0258
Practice Address - Fax:605-342-0209
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD725152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist