Provider Demographics
NPI:1730750399
Name:CLAYCOMB, COLE ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:COLE
Middle Name:ALAN
Last Name:CLAYCOMB
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 1:1813 WILLOW ST
Mailing Address - Street 2:STE 2A
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-4276
Mailing Address - Country:US
Mailing Address - Phone:812-881-5961
Mailing Address - Fax:
Practice Address - Street 1:1813 WILLOW ST # 2A
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-4276
Practice Address - Country:US
Practice Address - Phone:812-255-0559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004288A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist