Healthcare Provider Details

I. General information

NPI: 1851679625
Provider Name (Legal Business Name): CLARKSON OPTOMETRY ILLINOIS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 DADRIAN PROFESSIONAL PARK
GODFREY IL
62035-1685
US

IV. Provider business mailing address

PO BOX 207163
DALLAS TX
75320-7154
US

V. Phone/Fax

Practice location:
  • Phone: 636-200-4393
  • Fax: 618-467-1053
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-527-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number036058812
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateIL

VIII. Authorized Official

Name: JAMES WACHTER
Title or Position: CMO
Credential:
Phone: 636-200-4393