Provider Demographics
NPI:1538335864
Name:JODI L. CLARK O.D.
Entity type:Organization
Organization Name:JODI L. CLARK O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JODI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-370-3360
Mailing Address - Street 1:17001 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-3302
Mailing Address - Country:US
Mailing Address - Phone:310-370-3360
Mailing Address - Fax:
Practice Address - Street 1:17001 HAWTHORNE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-3302
Practice Address - Country:US
Practice Address - Phone:310-370-3360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9934T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU60802Medicare UPIN
CAOP9934Medicare PIN