NPIMap

Individual provider Active NPI

Kim M Clark, O.D.

  • Optometrist
  • Portland, OR
National Provider Identifier
1215091095
Registry record updated May 11, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
2911ATI Issued in OR
Practice address
12000 SE 82ND Avenue
#2012
Portland, OR 97266-7721
Phone
(503) 652-6001
Fax
(503) 652-6012
NPI assigned
Dec 19, 2006
Last updated
May 11, 2009By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 11, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X 2911ATI OR Primary

Addresses

Primary practice location

12000 SE 82ND Avenue
#2012
Portland, OR 97266-7721

Mailing address

2318 NW Edgewood PL
Portland, OR 97229-7618
Phone (503) 292-4033

Other names 1

  • Kim M Clark Professional name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

Practice roles

OrganizationSpecialtyStatusNew patients
Standard Optical Co Optometrist Past Accepting new patients
Standard Optical Co Optometrist Past Accepting new patients
Standard Optical Co Optometrist Past Accepting new patients
Standard Optical Co Optometrist Past Accepting new patients
Standard Optical Co Optometrist Past Accepting new patients
Standard Optical Co Optometrist Past Accepting new patients
Standard Optical Co Optometrist Past Accepting new patients

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1166486400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1242000000000",
    "number": "1215091095",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2318 NW EDGEWOOD PL",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972297618",
            "telephone_number": "503-292-4033",
            "fax_number": "503-292-2474"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12000 SE 82ND AVENUE",
            "address_2": "#2012",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972667721",
            "telephone_number": "503-652-6001",
            "fax_number": "503-652-6012"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "KIM",
        "middle_name": "M",
        "name_prefix": "Dr.",
        "credential": "O.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-12-19",
        "last_updated": "2009-05-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "OR",
            "license": "2911ATI",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KIM",
            "last_name": "CLARK",
            "middle_name": "M",
            "credential": "OD",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

Other providers in Portland, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 11, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.