Provider Demographics
NPI:1336209055
Name:CLARKE, SCOTT A (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:CLARKE
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 1:620 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2017
Mailing Address - Country:US
Mailing Address - Phone:217-348-0800
Mailing Address - Fax:217-248-0802
Practice Address - Street 1:620 6TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2017
Practice Address - Country:US
Practice Address - Phone:217-348-0800
Practice Address - Fax:217-348-0802
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008347152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008347Medicaid
ILP01161329Medicare PIN
ILIL2032001Medicare PIN