Provider Demographics
NPI:1760555189
Name:CLARK, CHARLES LAMOTTE (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LAMOTTE
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 1:4811 FAYETTEVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358
Mailing Address - Country:US
Mailing Address - Phone:910-739-3323
Mailing Address - Fax:910-739-6489
Practice Address - Street 1:4811 FAYETTEVILLE ROAD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358
Practice Address - Country:US
Practice Address - Phone:910-739-3323
Practice Address - Fax:910-739-6489
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1749152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0923LOtherBCBS
NC890923LMedicaid
NC2238827OtherUNITED HEALTHCARE
NC0923LOtherBCBS
2471726AMedicare PIN