Provider Demographics
NPI:1477723401
Name:CLARK, NANCY COPPIC (OD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:COPPIC
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 DEER RUN RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2863
Mailing Address - Country:US
Mailing Address - Phone:434-793-6912
Mailing Address - Fax:434-799-8641
Practice Address - Street 1:123 DEER RUN RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2863
Practice Address - Country:US
Practice Address - Phone:434-793-6912
Practice Address - Fax:434-799-8641
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010042917Medicaid
VA5130410001OtherDMERC
00V851N96Medicare PIN
VA010042917Medicaid