Provider Demographics
NPI:1952300832
Name:CLARK, STEPHEN BRENT (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BRENT
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 1:8390 NORTH HWY 27
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRING
Mailing Address - State:GA
Mailing Address - Zip Code:30739-2103
Mailing Address - Country:US
Mailing Address - Phone:706-375-1720
Mailing Address - Fax:706-375-1729
Practice Address - Street 1:8390 NORTH HWY 27
Practice Address - Street 2:
Practice Address - City:ROCK SPRING
Practice Address - State:GA
Practice Address - Zip Code:30739-2103
Practice Address - Country:US
Practice Address - Phone:706-375-1720
Practice Address - Fax:706-375-1729
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD002478152W00000X
GAOPT002352152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA194699738AMedicaid
GA1952569279OtherGROUP NPI
GA1952300832OtherBCBS
GA511G700557OtherMEDICARE
GA26-2355581OtherUHC
GA1952300832OtherBCBS
GA26-2355581OtherUHC