Healthcare Provider Details

I. General information

NPI: 1689015075
Provider Name (Legal Business Name): MELANIE DAWN CLARK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELANIE DAWN POPIEN

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3363 MERLIN DR
IDAHO FALLS ID
83404-7405
US

IV. Provider business mailing address

128 N 4010 E
RIGBY ID
83442-5787
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-0330
  • Fax: 208-534-9997
Mailing address:
  • Phone: 208-351-6616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100278
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: