Provider Demographics
NPI:1609849389
Name:CLARY, KATHLEEN A (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:CLARY
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 1:200 MOSAIC CIR
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-5025
Mailing Address - Country:US
Mailing Address - Phone:912-348-4584
Mailing Address - Fax:
Practice Address - Street 1:200 MOSAIC CIR
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-5025
Practice Address - Country:US
Practice Address - Phone:912-348-4584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-11
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000373152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD19772Medicaid
SCSCB632E499OtherSC MEDICARE