Provider Demographics
NPI:1013079771
Name:CLARK, CAROLYN SUE (OD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4925 BRADENTON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-7532
Mailing Address - Country:US
Mailing Address - Phone:614-792-1974
Mailing Address - Fax:614-760-1996
Practice Address - Street 1:4925 BRADENTON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-7532
Practice Address - Country:US
Practice Address - Phone:614-792-1974
Practice Address - Fax:614-760-1996
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH4089152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0762509Medicaid
OH0762509Medicaid
OHT89979Medicare UPIN