Provider Demographics
NPI:1891859682
Name:CLARK, JAMES JEFFREY (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JEFFREY
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 1:210 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-2663
Mailing Address - Country:US
Mailing Address - Phone:770-229-8700
Mailing Address - Fax:770-229-5008
Practice Address - Street 1:210 S 16TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-2663
Practice Address - Country:US
Practice Address - Phone:770-229-8700
Practice Address - Fax:770-229-5008
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1184152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000419218BMedicaid
GA000419218BMedicaid
GAU20040Medicare UPIN
GA1190080001Medicare NSC
GA41ZCDDWMedicare PIN