Basic Information
| Provider Information | |||||||||
| NPI: | 1326781147 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARKSON OPTOMETRY MIDWEST INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207170 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 MONROE RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450361414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139342020 | ||||||||
| FaxNumber: | 5139342028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2022 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | WACHTER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 6362004393 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.