Provider Demographics
NPI:1124382601
Name:CLARK, MEREDITH KATHERINE (O D)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:KATHERINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 REVOLUTION ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3748
Mailing Address - Country:US
Mailing Address - Phone:410-939-2200
Mailing Address - Fax:410-939-5980
Practice Address - Street 1:920 REVOLUTION ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3748
Practice Address - Country:US
Practice Address - Phone:410-939-2200
Practice Address - Fax:410-939-5980
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002639152W00000X
MDTA2371152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA13586OtherEYEMED
MDA13586OtherEYEMED