Basic Information
| Provider Information | |||||||||
| NPI: | 1326090267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARKSON OPTOMETRY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207158 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6369382650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | HOLT | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER OF CENTRAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6362004393 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | CE9167 | 01 | MO | RAILROAD MEDICARE | OTHER | 502027709 | 05 | MO | MEDICAID |