Provider Demographics
NPI:1639292535
Name:KLARK, RAYMOND A JR (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:A
Last Name:KLARK
Suffix:JR
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 PINEWOODS AVE
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-7068
Mailing Address - Country:US
Mailing Address - Phone:716-836-1909
Mailing Address - Fax:716-434-7809
Practice Address - Street 1:236 PINEWOODS AVE
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-7068
Practice Address - Country:US
Practice Address - Phone:716-836-1909
Practice Address - Fax:716-434-7809
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4077156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00707231Medicaid
NY0127020001Medicare ID - Type UnspecifiedVISION