Basic Information
| Provider Information | |||||||||
| NPI: | 1629135934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | TERRENCE | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34584 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092417349 | ||||||||
| FaxNumber: | 5092417628 | ||||||||
| Practice Location | |||||||||
| Address1: | 5821 SPRAGUE CT. | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533964200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD00001204 | WA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 2073807 | 05 | WA | MEDICAID |