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NPI Code Detail

MEDICARE: ANN M CLARK O.D.

MEDICARE: ANN M CLARK O.D.
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
1152W00000XOptometrist11622TCA

General Provider Information

NPI Number : 1093870925
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANN M CLARK O.D.
Provider Business Mailing Address
First Line : 1908 ROCKEFELLER LN
Second Line : #A
City : REDONDO BEACH
State : CA
Zip : 90278-3506
Country : US
Telephone Number : 310-798-9255
Fax Number : 310-798-9255
Provider Business Practice Location Address
First Line : 1760 S PACIFIC COAST HWY
Second Line :
City : REDONDO BEACH
State : CA
Zip : 90277-5902
Country : US
Telephone Number : 310-540-2970
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/22/2006
Last Update Date : 07/08/2007

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