Provider Demographics
NPI:1629370929
Name:PHILIP H. CLARK, O.D., P.A.
Entity Type:Organization
Organization Name:PHILIP H. CLARK, O.D., P.A.
Other - Org Name:CLARK EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:479-967-4711
Mailing Address - Street 1:302 N PHOENIX AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2828
Mailing Address - Country:US
Mailing Address - Phone:479-967-4711
Mailing Address - Fax:479-967-4485
Practice Address - Street 1:302 N PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2828
Practice Address - Country:US
Practice Address - Phone:479-967-4711
Practice Address - Fax:479-967-4485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2042152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104322722Medicaid
AR104322722Medicaid