Provider Demographics
NPI:1720004591
Name:CLARK, STEPHEN PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PAUL
Last Name:CLARK
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:PO BOX 826
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37371-0826
Mailing Address - Country:US
Mailing Address - Phone:423-745-8882
Mailing Address - Fax:423-744-8428
Practice Address - Street 1:902 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3432
Practice Address - Country:US
Practice Address - Phone:423-745-8882
Practice Address - Fax:423-744-8428
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1668152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN14981OtherSPECTERA
TN0350810001OtherDMERC
TN2240022OtherUNITED HEALTHCARE
TN3029708OtherBLUE CROSS BLUE SHIELD TN
TN9812003OtherCIGNA
TN3940201Medicaid
TN2240022OtherUNITED HEALTHCARE
TN3940201Medicare ID - Type Unspecified