Provider Demographics
NPI:1801063664
Name:CLARK, CHRISTOPHER M (LICENSED OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4833 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2563
Mailing Address - Country:US
Mailing Address - Phone:540-562-1380
Mailing Address - Fax:
Practice Address - Street 1:1960 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1601
Practice Address - Country:US
Practice Address - Phone:540-776-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101 002026156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAOP2378OtherEYEMED VISION CARE