MEDICARE: DR. BOYD A CLARK OD

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	FL 1463	FL

General Provider Information

NPI Number	:	1205830767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BOYD A CLARK OD

Provider Business Mailing Address
First Line	:	725 N TYNDALL PKWY
Second Line	:	C/O VISION CENTER
City	:	CALLAWAY
State	:	FL
Zip	:	32404-3219
Country	:	US
Telephone Number	:	850-785-0007
Fax Number	:	850-785-0009

Provider Business Practice Location Address
First Line	:	725 N TYNDALL PKWY
Second Line	:
City	:	CALLAWAY
State	:	FL
Zip	:	32404-3219
Country	:	US
Telephone Number	:	850-785-0007
Fax Number	:	850-785-0009

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

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	04/28/2016

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