Healthcare Provider Details

I. General information

NPI: 1609849389
Provider Name (Legal Business Name): KATHLEEN A. CLARY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2006
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MOSAIC CIR
POOLER GA
31322-5025
US

IV. Provider business mailing address

200 MOSAIC CIR
POOLER GA
31322-5025
US

V. Phone/Fax

Practice location:
  • Phone: 912-348-4584
  • Fax:
Mailing address:
  • Phone: 912-348-4584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618000373
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: