Provider Demographics
NPI:1760710958
Name:CLARK, NICHOLAS L (OD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:L
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD, LLC
Mailing Address - Street 1:2185 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-9108
Mailing Address - Country:US
Mailing Address - Phone:503-435-1231
Mailing Address - Fax:503-435-0151
Practice Address - Street 1:2185 NW 2ND ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-9108
Practice Address - Country:US
Practice Address - Phone:503-435-1231
Practice Address - Fax:503-435-0151
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-25
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3319 ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist