Provider Demographics
NPI:1083668974
Name:CLARKSON OPTOMETRY INC
Entity type:Organization
Organization Name:CLARKSON OPTOMETRY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WACHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-200-4393
Mailing Address - Street 1:15933 CLAYTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:14842 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4620
Practice Address - Country:US
Practice Address - Phone:636-200-4393
Practice Address - Fax:636-557-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0360070020Medicare NSC