Provider Demographics
NPI:1548432156
Name:GARY L. CLARKE, INC.
Entity Type:Organization
Organization Name:GARY L. CLARKE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-446-2525
Mailing Address - Street 1:308 SILVER BRIDGE PLZ
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1833
Mailing Address - Country:US
Mailing Address - Phone:740-446-2525
Mailing Address - Fax:740-446-4371
Practice Address - Street 1:308 SILVER BRIDGE PLZ
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1833
Practice Address - Country:US
Practice Address - Phone:740-446-2525
Practice Address - Fax:740-446-4371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150144000Medicaid
OH0345700Medicaid
WV0150144000Medicaid
OH0345700Medicaid
OH9263881Medicare PIN