Provider Demographics
NPI:1285699553
Name:CLARK, PATRICK JAMES JR (OD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JAMES
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:101 BODIN CIR
Mailing Address - Street 2:60 MDG/AMDS OPTOMETRY CLINIC
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1809
Mailing Address - Country:US
Mailing Address - Phone:707-423-7171
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:60 MDG/AMDS OPTOMETRY CLINIC
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10580T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist