Provider Demographics
NPI:1215776091
Name:CLARK, MALLORY (OD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:GLILMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:530 MOCKINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-3100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3430 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5732
Practice Address - Country:US
Practice Address - Phone:228-875-3318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist