Provider Demographics
NPI:1710022710
Name:CLARK, ORVILLE MAYO III (OD)
Entity Type:Individual
Prefix:DR
First Name:ORVILLE
Middle Name:MAYO
Last Name:CLARK
Suffix:III
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:PO BOX 632
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0632
Mailing Address - Country:US
Mailing Address - Phone:606-437-9955
Mailing Address - Fax:
Practice Address - Street 1:237 SECOND STREET
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501
Practice Address - Country:US
Practice Address - Phone:606-437-9955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0827DT152W00000X
VA0618001530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77008274Medicaid
KY77008274Medicaid