Provider Demographics
NPI:1184703159
Name:CLARK, TERRI S
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 HIGHWAY 6 SOUTH
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:IA
Mailing Address - Zip Code:51560-0323
Mailing Address - Country:US
Mailing Address - Phone:712-482-3686
Mailing Address - Fax:712-482-3636
Practice Address - Street 1:406 HIGHWAY 6 SOUTH
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:IA
Practice Address - Zip Code:51560-0323
Practice Address - Country:US
Practice Address - Phone:712-482-3686
Practice Address - Fax:712-482-3636
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0432617Medicaid