Basic Information
| Provider Information | |||||||||
| NPI: | 1184660227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK-GELBURD | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OPTOMETRIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229803648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409497126 | ||||||||
| FaxNumber: | 5409436170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 0618000978 | VA | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WP0200X | 0618000978 | VA | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WV0400X | 0618000978 | VA | N | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152W00000X | 0618000978 | VA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 033512 | 01 | VA | ANTHEM-VIRGINIA | OTHER |