Provider Demographics
NPI:1386824555
Name:CLARK, TILDEN DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:TILDEN
Middle Name:DAVID
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6485 WARWICK CIR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-3662
Mailing Address - Country:US
Mailing Address - Phone:703-971-9726
Mailing Address - Fax:
Practice Address - Street 1:6485 WARWICK CIR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-3662
Practice Address - Country:US
Practice Address - Phone:703-971-9726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000775152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist