Provider Demographics
NPI:1629113345
Name:CLARKE, CALVIN S (OD)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:S
Last Name:CLARKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4314 KEMP BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308
Mailing Address - Country:US
Mailing Address - Phone:940-691-5645
Mailing Address - Fax:
Practice Address - Street 1:4314 KEMP BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308
Practice Address - Country:US
Practice Address - Phone:940-691-5645
Practice Address - Fax:940-691-5653
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02116T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
81139EOtherBCBS
TX81139EMedicare PIN
T12673Medicare UPIN
TX4070960001Medicare NSC