MEDICARE: JODI L. 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

General Provider Information

NPI Number	:	1538335864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JODI L. CLARK O.D.

Provider Business Mailing 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	:

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	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. JODI LYNN CLARK
Credential	:	O.D.
Telephone Number	:	310-370-3360

Provider Enumeration Date	:	05/06/2008
Last Update Date	:	05/06/2008

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