Provider Demographics
NPI:1215091095
Name:CLARK, KIM M (OD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:M
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2318 NW EDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-7618
Mailing Address - Country:US
Mailing Address - Phone:503-292-4033
Mailing Address - Fax:503-292-2474
Practice Address - Street 1:12000 SE 82ND AVENUE
Practice Address - Street 2:#2012
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-7721
Practice Address - Country:US
Practice Address - Phone:503-652-6001
Practice Address - Fax:503-652-6012
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2911ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000009413Medicare ID - Type Unspecified