Provider Demographics
NPI:1720133671
Name:CLARK, THOMAS DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:DAVID
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:820 COBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-4287
Mailing Address - Country:US
Mailing Address - Phone:812-401-3508
Mailing Address - Fax:
Practice Address - Street 1:1401 N GREEN RIVER RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2428
Practice Address - Country:US
Practice Address - Phone:812-479-5025
Practice Address - Fax:812-479-5060
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002530 B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist