Provider Demographics
NPI:1851353007
Name:CLARKE, GREGORY R (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:CLARKE
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 1:2921 ERIE BLVD EAST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224
Mailing Address - Country:US
Mailing Address - Phone:315-445-7465
Mailing Address - Fax:315-445-7675
Practice Address - Street 1:4109 W GENESEE STREET
Practice Address - Street 2:EMPIRE VISION CENTERS
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219
Practice Address - Country:US
Practice Address - Phone:315-488-2020
Practice Address - Fax:315-488-2101
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT0038531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY53061NMedicare ID - Type Unspecified
T25900Medicare UPIN