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General NPI Number Information
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NPI Number | 1861482309
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Entity Type | Individual
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Provider Name | CLARK EDWARD DESHON O.D., F.A.A.O
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Gender | Male
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Dates
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Enumeration Date | 10/26/2005
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Last Update Date | 08/31/2018
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Provider Practice Location Address
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Address Line | 303 E MAIN ST
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City | OLNEY
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State | IL
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Zip | 62450
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Country | US
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Telephone | 618-395-2676
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Fax | 618-395-2720
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Provider Business Mailing Address
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Address Line | 303 E MAIN ST
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City | OLNEY
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State | IL
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Zip | 62450-2117
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Country | US
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Telephone | 618-395-2676
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Fax | 618-395-2720
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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 | 046008793
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License Number State | IL
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