Provider Demographics
NPI:1962444687
Name:DR. CLARK & ASSOCIATE OPTOMETRISTS, P.A.
Entity Type:Organization
Organization Name:DR. CLARK & ASSOCIATE OPTOMETRISTS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:FREDRICK
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:512-452-5735
Mailing Address - Street 1:5501 B NORTH IH 35
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-2430
Mailing Address - Country:US
Mailing Address - Phone:512-452-5735
Mailing Address - Fax:512-452-3119
Practice Address - Street 1:5501 B NORTH IH 35
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-2430
Practice Address - Country:US
Practice Address - Phone:512-452-5735
Practice Address - Fax:512-452-3119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0192825-01Medicaid
TX0192825-01Medicaid