Provider Demographics
NPI:1467521153
Name:CLARK, GREGORY ALEXANDER (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALEXANDER
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 1:16160 22ND PL N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-2382
Mailing Address - Country:US
Mailing Address - Phone:612-703-0298
Mailing Address - Fax:
Practice Address - Street 1:12547 RIVERDALE BLVD NW
Practice Address - Street 2:COSTCO OPTICAL DEPARTMENT
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-6708
Practice Address - Country:US
Practice Address - Phone:763-712-7761
Practice Address - Fax:763-712-7787
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2806152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN163474700Medicaid
MN410001679Medicare ID - Type Unspecified
MN163474700Medicaid