Basic Information
| Provider Information | |||||||||
| NPI: | 1760555189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | LAMOTTE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4811 FAYETTEVILLE ROAD | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107393323 | ||||||||
| FaxNumber: | 9107396489 | ||||||||
| Practice Location | |||||||||
| Address1: | 4811 FAYETTEVILLE ROAD | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107393323 | ||||||||
| FaxNumber: | 9107396489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
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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 | 1749 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0923L | 01 | NC | BCBS | OTHER | 890923L | 05 | NC | MEDICAID | 2238827 | 01 | NC | UNITED HEALTHCARE | OTHER |