Provider Demographics
NPI:1689015075
Name:CLARK, MELANIE DAWN (OD)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:DAWN
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:DAWN
Other - Last Name:POPIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3731 E 100 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5612
Mailing Address - Country:US
Mailing Address - Phone:208-351-6616
Mailing Address - Fax:
Practice Address - Street 1:1480 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2128
Practice Address - Country:US
Practice Address - Phone:208-525-8686
Practice Address - Fax:208-525-8684
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100278152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist