MEDICARE: CLARKSON OPTOMETRY MIDWEST INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FC0800X	Contact Lens Technician/Technologist
2	152WX0102X	Occupational Vision Optometrist	002917	OH
3	156FX1800X	Optician	5838	OH
4	152W00000X	Optometrist	3934	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4704870001	OTHER	OH	MEDICARE PTAN

General Provider Information

NPI Number	:	1083642086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKSON OPTOMETRY MIDWEST INC

Provider Business Mailing Address
First Line	:	PO BOX 207170
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75320-7156
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-527-0766

Provider Business Practice Location Address
First Line	:	3600 OLENTANGY RIVER RD STE B
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43214-3437
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	614-545-0749

Authorized Official
Title or Position	:	CMO
Name	:	JAMES WACHTER
Credential	:
Telephone Number	:	636-200-4393

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	06/07/2019

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