MEDICARE: CLARKSON EYECARE

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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1164475810
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKSON EYECARE

Provider Business Mailing Address
First Line	:	2404 TAYLOR RD
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63040-1222
Country	:	US
Telephone Number	:	636-458-8787
Fax Number	:

Provider Business Practice Location Address
First Line	:	2404 TAYLOR RD
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63040-1222
Country	:	US
Telephone Number	:	636-458-8787
Fax Number	:

Authorized Official
Title or Position	:	MANAGER OF CENTRAL OPERATIONS
Name	:	KRIS CALDWELL
Credential	:
Telephone Number	:	636-200-4393

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	11/21/2007

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Directions to “CLARKSON EYECARE ” Practice Location

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