Provider Demographics
NPI:1740478403
Name:CLARK, NICKOLAS WILSON (OD)
Entity type:Individual
Prefix:MR
First Name:NICKOLAS
Middle Name:WILSON
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:122 TAZEWELL ST
Mailing Address - Street 2:
Mailing Address - City:PEARISBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24134-1632
Mailing Address - Country:US
Mailing Address - Phone:540-921-3921
Mailing Address - Fax:540-921-1328
Practice Address - Street 1:122 TAZEWELL ST
Practice Address - Street 2:
Practice Address - City:PEARISBURG
Practice Address - State:VA
Practice Address - Zip Code:24134
Practice Address - Country:US
Practice Address - Phone:540-921-3921
Practice Address - Fax:540-921-1328
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002202152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist