MEDICARE: CHARLES A 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	01637	IA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	410045287	OTHER	IA	RAILROAD MEDICARE

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	:	1922090752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES A CLARK OD

Provider Business Mailing Address
First Line	:	212 N FRANKLIN ST
Second Line	:	PO BOX 611
City	:	CORYDON
State	:	IA
Zip	:	50060-1328
Country	:	US
Telephone Number	:	641-774-5819
Fax Number	:	641-774-8415

Provider Business Practice Location Address
First Line	:	212 N FRANKLIN ST
Second Line	:
City	:	CORYDON
State	:	IA
Zip	:	50060-1328
Country	:	US
Telephone Number	:	641-774-5819
Fax Number	:	641-774-8415

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	07/12/2016

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Directions to “ CHARLES A CLARK OD” Practice Location

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