Provider Demographics
NPI:1134194269
Name:CLARK, PATRICIA A (OD)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:A
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:PO BOX 60834
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01116-0834
Mailing Address - Country:US
Mailing Address - Phone:413-567-6450
Mailing Address - Fax:413-754-6723
Practice Address - Street 1:809 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-2060
Practice Address - Country:US
Practice Address - Phone:413-567-6450
Practice Address - Fax:413-754-6723
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAOPT4613152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236396Medicaid
410001075Medicare ID - Type Unspecified
CT004236396Medicaid