Provider Demographics
NPI:1861482309
Name:DESHON, CLARK EDWARD (OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:EDWARD
Last Name:DESHON
Suffix:
Gender:M
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2117
Mailing Address - Country:US
Mailing Address - Phone:618-395-2676
Mailing Address - Fax:618-395-2720
Practice Address - Street 1:303 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450
Practice Address - Country:US
Practice Address - Phone:618-395-2676
Practice Address - Fax:618-395-2720
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008793152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5290131OtherAETNA
IL046008793Medicaid
IL09327152OtherBLUE CROSS BLUE SHIELD
ILU36374Medicare UPIN
IL5290131OtherAETNA
IL540140Medicare ID - Type Unspecified