Provider Demographics
NPI:1619197779
Name:CLARK, STEVEN JAMES (LD0001859)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:JAMES
Last Name:CLARK
Suffix:
Gender:M
Credentials:LD0001859
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4292 GRAY HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032
Mailing Address - Country:US
Mailing Address - Phone:478-986-2384
Mailing Address - Fax:478-986-2301
Practice Address - Street 1:4292 GRAY HWY
Practice Address - Street 2:SUITE A
Practice Address - City:GRAY
Practice Address - State:GA
Practice Address - Zip Code:31032
Practice Address - Country:US
Practice Address - Phone:478-986-2384
Practice Address - Fax:478-986-2301
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD0001859156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0495930001Medicare ID - Type Unspecified