NPIMap

Organization Active NPI

Clarkson Optometry Midwest Inc.

  • Optometrist
  • Benton, KY
National Provider Identifier
1497948541
Registry record updated Jul 8, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
1073DT Issued in KY
Legal business name
CLARKSON OPTOMETRY MIDWEST INC.
Practice address
109 W 5TH St
Benton, KY 42025-1123
Phone
(636) 200-4393
NPI assigned
Aug 22, 2007
Last updated
Jul 8, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 8, 2019

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

Authorized official

Name
James WachterNPI 1689670697
Title
Owner
Phone
(636) 200-4393

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X 1073DT KY Primary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X 1469DT KY
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X 1767DT KY

Addresses

Primary practice location

109 W 5TH St
Benton, KY 42025-1123

Mailing address

PO Box 207170
Dallas, TX 75320-7156
Phone (636) 200-4393

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190716002507 KY DME Supplier - Physician - Optometrist 0749504165 Practice locations: Benton, KY

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Clarkson Optometry Mid Inc23 organizations share this tax ID, including this one

Other organizations with this tax ID 22

Organizations that report the same tax identification number in the National Provider Directory.

View all 22

Locations

15933 Clayton Rd
Dallas, TX 75320

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1187740800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1562544000000",
    "number": "1497948541",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 207170",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "753207156",
            "telephone_number": "636-200-4393",
            "fax_number": "636-527-0766"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "109 W 5TH ST",
            "city": "BENTON",
            "state": "KY",
            "postal_code": "420251123",
            "telephone_number": "636-200-4393"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLARKSON OPTOMETRY MIDWEST INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-08-22",
        "last_updated": "2019-07-08",
        "status": "A",
        "authorized_official_last_name": "WACHTER",
        "authorized_official_first_name": "JAMES",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "636-200-4393"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "KY",
            "license": "1073DT",
            "primary": true
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "KY",
            "license": "1469DT",
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "KY",
            "license": "1767DT",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Benton, KY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.