Physician Compare National (NPI:1487008603)

HEALTHCARE PROVIDER: DOUGLAS ROBERT CLARK O.D.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1487008603
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	3577820521
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20190625003327
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	CLARK
	Individual professional last name
Provider First Name	DOUGLAS
	Individual professional first name
Provider Middle Name	ROBERT
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	FERRIS STATE COLLEGE - COLLEGE OF OPTOMETRY
	Individual professional's medical school
Graduation Year	2016
	Individual professional's medical school graduation year
Primary Specialty	OPTOMETRY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	446 N STATE RD
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 198
	Group Practice or individual's line 2 address
City	SALEM
	Group Practice or individual's city
State	UT
	Group Practice or individual's state
Zip Code	846534605
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Professional Accepts Medicare Assignment	Y