Basic Information
| Provider Information | |||||||||
| NPI: | 1144712035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | NATHANIEL | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 S RACEWAY RD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462311414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172738474 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 S RACEWAY RD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462311414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172738474 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2018 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18004088A | IN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.