MEDICARE: DR. JODI LYNN CLARK O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	9934T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053319673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JODI LYNN CLARK O.D.

Provider Business Mailing Address
First Line	:	202 VIA MESA GRANDE
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-6639
Country	:	US
Telephone Number	:	310-373-1624
Fax Number	:

Provider Business Practice Location Address
First Line	:	17001 HAWTHORNE BLVD
Second Line	:	SUITE B
City	:	LAWNDALE
State	:	CA
Zip	:	90260-3302
Country	:	US
Telephone Number	:	310-370-3360
Fax Number	:	310-370-6227

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	04/30/2008

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