Healthcare Provider Details

I. General information

NPI: 1699808295
Provider Name (Legal Business Name): DOUGLAS C CLARK, OD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2617 PELHAM PKWY
PELHAM AL
35124-1322
US

IV. Provider business mailing address

2617 PELHAM PKWY
PELHAM AL
35124-1322
US

V. Phone/Fax

Practice location:
  • Phone: 205-664-1575
  • Fax: 205-664-1578
Mailing address:
  • Phone: 205-664-1575
  • Fax: 205-664-1578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateAL

VIII. Authorized Official

Name: DR. DOUGLAS CURTIS CLARK
Title or Position: OWNER
Credential: O.D.
Phone: 205-664-1575