MEDICARE: CLARKSON OPTOMETRY ILLINOIS, P.C.

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	036104178	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730373648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKSON OPTOMETRY ILLINOIS, P.C.

Provider Business Mailing Address
First Line	:	PO BOX 207163
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75320-7154
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-527-0766

Provider Business Practice Location Address
First Line	:	408 W 2ND ST
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3402
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	618-532-6706

Authorized Official
Title or Position	:	CMO
Name	:	JAMES WACHTER
Credential	:
Telephone Number	:	636-200-4393

Provider Enumeration Date	:	09/04/2007
Last Update Date	:	06/06/2019

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