Provider Demographics
NPI:1295142362
Name:CLARK, PHILIP (LDO)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 N 16TH ST
Mailing Address - Street 2:160
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5347
Mailing Address - Country:US
Mailing Address - Phone:602-277-5007
Mailing Address - Fax:
Practice Address - Street 1:4201 N 16TH ST
Practice Address - Street 2:160
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5347
Practice Address - Country:US
Practice Address - Phone:602-277-5007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ417156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician