MEDICARE: JAVEYA CLARK 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	OPT003200	GA

General Provider Information

NPI Number	:	1891345575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAVEYA CLARK OD

Provider Business Mailing Address
First Line	:	1568 REEL LAKE DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-8961
Country	:	US
Telephone Number	:	251-714-6261
Fax Number	:

Provider Business Practice Location Address
First Line	:	3645 HABERSHAM RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-1130
Country	:	US
Telephone Number	:	404-549-9999
Fax Number	:

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

Provider Enumeration Date	:	09/16/2019
Last Update Date	:	09/16/2019

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