Provider Demographics
NPI:1255391595
Name:CLARKE, DAVID G (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
Last Name:CLARKE
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 1:215 N KANAWHA ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4716
Mailing Address - Country:US
Mailing Address - Phone:304-253-2020
Mailing Address - Fax:304-253-2340
Practice Address - Street 1:215 N KANAWHA ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4716
Practice Address - Country:US
Practice Address - Phone:304-253-2020
Practice Address - Fax:304-253-2340
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV827OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149237000Medicaid
WV9303481Medicare ID - Type Unspecified
T32436Medicare UPIN