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General NPI Number Information
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NPI Number | 1952425654
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Entity Type | Organization
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Legal Business Name | THE CLARK EYE CLINIC, PC
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 01/25/2010
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Provider Practice Location Address
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Address Line | 502 ISABELLA ST
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City | WAYCROSS
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State | GA
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Zip | 31501-3638
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Country | US
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Telephone | 912-285-2020
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Fax | 912-285-8112
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Provider Business Mailing Address
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Address Line | PO BOX 2009
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City | WAYCROSS
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State | GA
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Zip | 31502-2009
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Country | US
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Telephone | 912-285-2020
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Fax | 912-285-8112
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Authorized Official
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Title or Position | OWNER
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Name | SPURGEON WILLIAM CLARK III
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Credential | M.D.
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Telephone | 912-285-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 24916
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License Number State | GA
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