Provider Demographics
NPI:1528059565
Name:CLARK, RICHARD K (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:K
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 1:810 NE 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34470-6335
Mailing Address - Country:US
Mailing Address - Phone:352-732-0046
Mailing Address - Fax:352-732-2649
Practice Address - Street 1:810 NE 25TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-6335
Practice Address - Country:US
Practice Address - Phone:352-732-0046
Practice Address - Fax:352-732-2649
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2341152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086895700Medicaid
FL19818OtherBLUE CROSS BLUE SHIELD
FL0847700001Medicare NSC
FLK1714Medicare ID - Type Unspecified
FLU09415Medicare UPIN