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General NPI Number Information
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NPI Number | 1033220868
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Entity Type | Individual
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Provider Name | JOHN ALFRED CLARK O.D.
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Gender | Male
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4000 CENTRAL FLORIDA BLVD UNIVERSITY OF CENTRAL FL. - STUDENT UNION BLDG.
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City | ORLANDO
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State | FL
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Zip | 32816-8005
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Country | US
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Telephone | 407-823-4017
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Fax |
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Provider Business Mailing Address
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Address Line | 11225 BRONSON RD
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City | CLERMONT
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State | FL
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Zip | 34711-9318
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Country | US
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Telephone | 352-409-5783
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODTA00379
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License Number State | RI
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OP 1726
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License Number State | FL
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