Provider Demographics
NPI:1689643926
Name:PATRICK, TERRY CLARK (OD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:CLARK
Last Name:PATRICK
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 1:610 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-1902
Mailing Address - Country:US
Mailing Address - Phone:406-293-6236
Mailing Address - Fax:
Practice Address - Street 1:610 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-1902
Practice Address - Country:US
Practice Address - Phone:406-293-6236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT689152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT481525Medicaid
MT481525Medicaid
MT000025125Medicare PIN