Provider Demographics
NPI:1700431749
Name:CLARK, ADAM (OD)
Entity Type:Individual
Prefix:
First Name:ADAM
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 1:341 W TUDOR RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-6639
Mailing Address - Country:US
Mailing Address - Phone:907-770-6652
Mailing Address - Fax:
Practice Address - Street 1:341 W TUDOR RD STE 101
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-6639
Practice Address - Country:US
Practice Address - Phone:907-770-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK147655152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist