Provider Demographics
NPI:1043321169
Name:CLARK, DWIGHT EUGENE (OD)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:EUGENE
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 1:11216 TRINITY RIVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670
Mailing Address - Country:US
Mailing Address - Phone:916-635-6161
Mailing Address - Fax:916-631-3788
Practice Address - Street 1:11216 TRINITY RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670
Practice Address - Country:US
Practice Address - Phone:916-635-6161
Practice Address - Fax:916-631-3788
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0055120Medicaid
CASD0055120Medicaid