Healthcare Provider Details

I. General information

NPI: 1225087943
Provider Name (Legal Business Name): CLARENCE DAVID VESELY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTUHL REGIONAL MEDICAL CENTER CMR 402, BOX 2078
APO AE
09180
US

IV. Provider business mailing address

CMR 402 BOX 2078
APO AE
09180
US

V. Phone/Fax

Practice location:
  • Phone: 011496371868532
  • Fax:
Mailing address:
  • Phone: 011496371868532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3098
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: