Provider Demographics
NPI:1770767733
Name:SHANNON L CLARK O D P A
Entity type:Organization
Organization Name:SHANNON L CLARK O D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:L W
Authorized Official - Last Name:CLARK LEITENBAUER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:772-465-6616
Mailing Address - Street 1:2305 OLEANDER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5830
Mailing Address - Country:US
Mailing Address - Phone:772-465-6616
Mailing Address - Fax:
Practice Address - Street 1:2305 OLEANDER BLVD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5830
Practice Address - Country:US
Practice Address - Phone:772-465-6616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 0003067332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1231240001Medicare NSC