Provider Demographics
NPI:1144712035
Name:CLARK, NATHANIEL (OD)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S RACEWAY RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46231-1414
Mailing Address - Country:US
Mailing Address - Phone:317-273-8474
Mailing Address - Fax:
Practice Address - Street 1:105 S RACEWAY RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46231-1414
Practice Address - Country:US
Practice Address - Phone:317-273-8474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004088A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist