Provider Demographics
NPI:1487626743
Name:CLARK, BEN P (OD)
Entity Type:Individual
Prefix:DR
First Name:BEN
Middle Name:P
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:P
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 1307
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-1307
Mailing Address - Country:US
Mailing Address - Phone:843-237-7055
Mailing Address - Fax:
Practice Address - Street 1:116 BASKERVILL DR
Practice Address - Street 2:
Practice Address - City:PALWEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585
Practice Address - Country:US
Practice Address - Phone:843-357-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU65548Medicare UPIN
SC8488Medicare PIN