Provider Demographics
NPI:1609900711
Name:CLARK OPTOMETRY, P.C.
Entity Type:Organization
Organization Name:CLARK OPTOMETRY, P.C.
Other - Org Name:CLARK EYE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENTCEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-781-2650
Mailing Address - Street 1:81 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1737
Mailing Address - Country:US
Mailing Address - Phone:315-781-2650
Mailing Address - Fax:315-781-1970
Practice Address - Street 1:81 NORTH ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1737
Practice Address - Country:US
Practice Address - Phone:315-781-2650
Practice Address - Fax:315-781-1970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT005491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY100190CSOtherPREFERRED CARE
NYU-57589Medicare UPIN
NY100190CSOtherPREFERRED CARE
NYBA0028Medicare ID - Type Unspecified
NY4935210001Medicare ID - Type UnspecifiedD-MERC