=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952300832
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN BRENT CLARK O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2005
-----------------------------------------------------
Last Update Date | 07/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8390 NORTH HWY 27
-----------------------------------------------------
City | ROCK SPRING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30739-2103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-375-1720
-----------------------------------------------------
Fax | 706-375-1729
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8390 NORTH HWY 27
-----------------------------------------------------
City | ROCK SPRING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30739-2103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-375-1720
-----------------------------------------------------
Fax | 706-375-1729
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OD002478
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT002352
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------