Provider Demographics
NPI:1447394200
Name:CLAY, GARLAND WILLIS JR (OD)
Entity Type:Individual
Prefix:
First Name:GARLAND
Middle Name:WILLIS
Last Name:CLAY
Suffix:JR
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:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402
Mailing Address - Country:US
Mailing Address - Phone:580-223-8676
Mailing Address - Fax:580-223-8677
Practice Address - Street 1:226 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401
Practice Address - Country:US
Practice Address - Phone:580-223-8676
Practice Address - Fax:580-223-8677
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0731150001OtherPALMETTO
T40394Medicare UPIN