=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033763016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA CLARK OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2019
-----------------------------------------------------
Last Update Date | 02/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2878 MILLER DR
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46563-8094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-935-3937
-----------------------------------------------------
Fax | 574-936-4942
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 E 4TH ST STE 440
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62002-6206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18004186A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------