Provider Demographics
NPI:1952595878
Name:CLARKSON OPTOMETRY ILLINOIS PC
Entity Type:Organization
Organization Name:CLARKSON OPTOMETRY ILLINOIS PC
Other - Org Name:CLARKSON EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:WACHTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:636-200-4393
Mailing Address - Street 1:15933 CLAYTON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:210 S MAIN
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278
Practice Address - Country:US
Practice Address - Phone:618-635-3535
Practice Address - Fax:618-282-2830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104178Medicaid
IL046008176Medicaid
IL0460085471Medicaid
IL0460089501Medicaid
203195OtherPTAN
IL0460069901Medicaid
IL046006474Medicaid
IL0460078192Medicaid
IL0460089082Medicaid
203193OtherPTAN
203194OtherPTAN
U34723Medicare UPIN
U13846Medicare UPIN
K07867Medicare UPIN
IL0460069901Medicaid
IL0460089501Medicaid
IL046008176Medicaid
IL046006474Medicaid
IL0460089082Medicaid