Provider Demographics
NPI:1700015880
Name:CLARKSON OPTOMETRY MIDWEST INC
Entity Type:Organization
Organization Name:CLARKSON OPTOMETRY MIDWEST INC
Other - Org Name:EYECARE ASSOCIATES OF KENTUCKY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WACHTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:636-200-4393
Mailing Address - Street 1:PO BOX 207170
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7156
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:
Practice Address - Street 1:60 LAKEVIEW DR
Practice Address - Street 2:SUITE 2
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-5633
Practice Address - Country:US
Practice Address - Phone:270-554-2000
Practice Address - Fax:270-554-2989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1056DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY410043379OtherRAILROAD RETIREMENT MEDICARE
000000204120OtherANTHEM
KYT54717Medicare UPIN
KY410043379OtherRAILROAD RETIREMENT MEDICARE
KY9229601Medicare PIN