MEDICARE: CLARKSON OPTOMETRY MIDWEST INC

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	:	1730769696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKSON OPTOMETRY MIDWEST INC

Provider Business Mailing Address
First Line	:	PO BOX 207170
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75320-7173
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-527-0766

Provider Business Practice Location Address
First Line	:	3510 MANCHESTER RD
Second Line	:
City	:	COVENTRY TOWNSHIP
State	:	OH
Zip	:	44319-1415
Country	:	US
Telephone Number	:	330-753-2100
Fax Number	:	330-633-7165

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

Provider Enumeration Date	:	04/13/2021
Last Update Date	:	04/13/2021

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