Provider Demographics
NPI:1992750616
Name:CLARK, DEMETRICE (OD)
Entity type:Individual
Prefix:
First Name:DEMETRICE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GLADE PARK RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8683
Mailing Address - Country:US
Mailing Address - Phone:919-363-2146
Mailing Address - Fax:
Practice Address - Street 1:2216 E NC HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-2208
Practice Address - Country:US
Practice Address - Phone:919-544-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1385152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U12276Medicare UPIN