Gregory Alexander Clark, O.D.

Primary specialty

OptometristTaxonomy code 152W00000X

License

2806 Issued in MN

Practice address

12547 Riverdale Blvd NW
Costco Optical Department
Coon Rapids, MN 55448-6708

Phone

(763) 712-7761

Fax

(763) 712-7787

NPI assigned

Nov 7, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Optometry

Education

Illinois College of Optometry at Chicago, 2001

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Gregory Clark, O.D., Inc.Group PAC ID 5799880142, 3 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

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

• Gregory Clark, O.D., Inc.

  • Optometrist
  • Coon Rapids, MN
  • NPI 1801965504
  Medicare reassignment Care Compare group NPD Authorized official

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

{
    "created_epoch": "1162857600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1354147200000",
    "number": "1467521153",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16160 22ND PL N",
            "city": "PLYMOUTH",
            "state": "MN",
            "postal_code": "554472382",
            "telephone_number": "612-703-0298"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12547 RIVERDALE BLVD NW",
            "address_2": "COSTCO OPTICAL DEPARTMENT",
            "city": "COON RAPIDS",
            "state": "MN",
            "postal_code": "554486708",
            "telephone_number": "763-712-7761",
            "fax_number": "763-712-7787"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "GREGORY",
        "middle_name": "ALEXANDER",
        "name_prefix": "Dr.",
        "credential": "O.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-11-07",
        "last_updated": "2012-11-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "MN",
            "license": "2806",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "163474700",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jaehoon Cho, M.D.
• Alexi Mercedes Christensen, MA, OTR/L
• Judy Christy, NP
• Grace Chun, MD
• Grace Anne Cimino, M.S.
• Misty Lee Clark
• Rachel Clark, PTA
• CLD - Coon Rapids MN, LLC
• Jay Robert Clemens, LADC
• Jenna Michele Clements, PA

• Optometrist in Coon Rapids, MN
• Providers in Coon Rapids, MN by specialty
• Optometrist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 29, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.