Basic Information
| Provider Information | |||||||||
| NPI: | 1912932666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLOVER-DANQUE | ||||||||
| FirstName: | CLARISSA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GLOVER | ||||||||
| OtherFirstName: | CLARISSA | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 275 W. 28TH STREET | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853647304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287821980 | ||||||||
| FaxNumber: | 9283452950 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 W. 28TH STREET | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853647304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287821980 | ||||||||
| FaxNumber: | 9283452950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 07/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1682 | AZ | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | S-A73-TA-641 | AL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2535 | NC | N | Eye and Vision Services Providers | Optometrist |
No ID Information.