MEDICARE: DR. JASON 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
1	152W00000X	Optometrist	2012021505	MO

General Provider Information

NPI Number	:	1699024695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON M CLARK O.D.

Provider Business Mailing Address
First Line	:	101 CONLEY RD
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-6465
Country	:	US
Telephone Number	:	573-875-1126
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 CONLEY RD
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-6465
Country	:	US
Telephone Number	:	573-875-1126
Fax Number	:

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

Provider Enumeration Date	:	09/05/2012
Last Update Date	:	09/05/2012

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