Basic Information
| Provider Information | |||||||||
| NPI: | 1952595878 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARKSON OPTOMETRY ILLINOIS PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CLARKSON EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15933 CLAYTON RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630112172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 S MAIN | ||||||||
| Address2: | |||||||||
| City: | RED BUD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186353535 | ||||||||
| FaxNumber: | 6182822830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2007 | ||||||||
| LastUpdateDate: | 01/31/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WACHTER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 6362004393 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 036104178 | 05 | IL | MEDICAID | 046008176 | 05 | IL | MEDICAID | 0460085471 | 05 | IL | MEDICAID | 0460089501 | 05 | IL | MEDICAID | 203195 | 01 | PTAN | OTHER | 0460069901 | 05 | IL | MEDICAID | 046006474 | 05 | IL | MEDICAID | 0460078192 | 05 | IL | MEDICAID | 0460089082 | 05 | IL | MEDICAID | 203193 | 01 | PTAN | OTHER | 203194 | 01 | PTAN | OTHER |