=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629370929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILIP H. CLARK, O.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2010
-----------------------------------------------------
Last Update Date | 10/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 N PHOENIX AVE
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72801-2828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-967-4711
-----------------------------------------------------
Fax | 479-967-4485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 302 N PHOENIX AVE
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72801-2828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-967-4711
-----------------------------------------------------
Fax | 479-967-4485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | PHILIP H CLARK
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 479-967-4711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | AR2042
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------