Provider Demographics
NPI:1043301757
Name:CAMPBELL, CLARK D (OD)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:D
Last Name:CAMPBELL
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 1:5537 E THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-3658
Mailing Address - Country:US
Mailing Address - Phone:602-881-4545
Mailing Address - Fax:
Practice Address - Street 1:5537 E THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-3658
Practice Address - Country:US
Practice Address - Phone:602-881-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ341152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86-0434223OtherTAX ID NUMBER
AZZ162074Medicare PIN
AZ86-0434223OtherTAX ID NUMBER
AZZ162799Medicare PIN