The Clark Eye Clinic, PC
Organization Active NPI Ophthalmology Physician · Waycross, GA
NPI 1952425654 · NPPES record last updated Jan 25, 2010
Key facts
- NPI
- 1952425654
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Ophthalmology Physician 207W00000X
- License
- 24916 (GA)
- Legal business name
- THE CLARK EYE CLINIC, PC
- Practice address
- 502 Isabella St
Waycross, GA 31501-3638 - Phone
- (912) 285-2020
- Fax
- (912) 285-8112
- NPI assigned
- Mar 19, 2007
- Organization subpart
- No
Authorized official
- Name
- Spurgeon William Clark III, M.D.
- Title
- Owner
- Phone
- (912) 285-2020
Practitioners 1
-
Spurgeon William Clark III, M. D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 11D2213784 | Clark Eye Clinic, PC | Certificate of waiver | Feb 16, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in GA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040427000751 | GA | Part B Supplier - Clinic/Group Practice | 7113914755 |
Receives reassigned benefits from 1 practitioner Practice locations: Waycross, GA |
National Provider Directory
Locations
502 Isabella St
Waycross, GA 31501
Phone (912) 285-2020
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Ophthalmology Physician |
207W00000X | 24916 | GA | Yes |
Addresses
Primary practice location
502 Isabella St
Waycross, GA 31501-3638
Mailing address
PO Box 2009
Waycross, GA 31502-2009
Phone (912) 285-2020
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| CF4836 | Other | GA | RAILROAD MEDICARE |
| 00264547B3 | Medicaid | GA | |
| 024581 | Other | GA | BLUE CROSS BLUE SHIELD |
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All providers in Waycross, GA · Ophthalmology Physician in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 25, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.