Provider Demographics
NPI:1205903754
Name:CLARK, SCOTT (OD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 RANTOUL ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-3231
Mailing Address - Country:US
Mailing Address - Phone:508-837-3790
Mailing Address - Fax:
Practice Address - Street 1:491 RANTOUL ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-3231
Practice Address - Country:US
Practice Address - Phone:508-922-4732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3055152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA40857OtherFALLON
MA003055OtherTUFTS
MAW15719OtherBCBS
MADM9725OtherHPHC
MA0353442Medicaid
MAW17264Medicare PIN
MA0353442Medicaid