MEDICARE: DR. CLARK EDWARD FIELDEN 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
1	152W00000X	Optometrist	5704014-8904	UT

General Provider Information

NPI Number	:	1457339285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLARK EDWARD FIELDEN O.D.

Provider Business Mailing Address
First Line	:	2028 W 2220 N
Second Line	:
City	:	CLINTON
State	:	UT
Zip	:	84015-5744
Country	:	US
Telephone Number	:	801-779-0708
Fax Number	:

Provider Business Practice Location Address
First Line	:	2028 W 2220 N
Second Line	:
City	:	CLINTON
State	:	UT
Zip	:	84015-5744
Country	:	US
Telephone Number	:	801-779-0708
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	01/20/2021

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