1407936008 NPI number — DR MICHAEL CLARK OPTOMETRIST PA

Table of content: (NPI 1407936008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407936008 NPI number — DR MICHAEL CLARK OPTOMETRIST PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR MICHAEL CLARK OPTOMETRIST PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407936008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
602 S RENFRO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT AIRY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27030-4742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-789-9031
Provider Business Mailing Address Fax Number:
336-789-8343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 S RENFRO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT AIRY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27030-4742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-789-9031
Provider Business Practice Location Address Fax Number:
336-789-8343
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
336-789-9031

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0884 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 89013MW , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3739 . This is a "BLUE MEDICARE HMO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1409898 . This is a "UNITED MINE WORKERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9203311 . This is a "VIRGINIA MEDICAID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 013MW . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 580000014 . This is a "PALMETTO GBA--RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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