Provider Demographics
NPI:1891859278
Name:CLARK, KEVIN LANDIS (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LANDIS
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11604 COLEEN WAY
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-6922
Mailing Address - Country:US
Mailing Address - Phone:915-593-6205
Mailing Address - Fax:915-592-8868
Practice Address - Street 1:10415 GATEWAY BLVD W
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7905
Practice Address - Country:US
Practice Address - Phone:915-592-6885
Practice Address - Fax:915-595-4059
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4070T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist