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General NPI Number Information
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NPI Number | 1205820081
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Entity Type | Individual
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Provider Name | DARYLE L CLARK OD
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Gender | Male
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Dates
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Enumeration Date | 09/07/2005
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Last Update Date | 12/05/2015
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Provider Practice Location Address
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Address Line | 312 E LAKEWAY RD
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City | GILLETTE
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State | WY
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Zip | 82718-6329
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Country | US
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Telephone | 307-687-7353
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Fax | 307-686-1052
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Provider Business Mailing Address
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Address Line | 312 E LAKEWAY RD
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City | GILLETTE
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State | WY
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Zip | 82718-6329
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Country | US
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Telephone | 307-686-2010
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Fax | 307-686-1052
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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 | 191T
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License Number State | WY
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