MEDICARE: CALVIN S CLARKE OD

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	02116T	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	81139E	OTHER		BCBS

General Provider Information

NPI Number	:	1629113345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALVIN S CLARKE OD

Provider Business Mailing Address
First Line	:	4314 KEMP BLVD
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308
Country	:	US
Telephone Number	:	940-691-5645
Fax Number	:

Provider Business Practice Location Address
First Line	:	4314 KEMP BLVD
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308
Country	:	US
Telephone Number	:	940-691-5645
Fax Number	:	940-691-5653

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

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	03/10/2011

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