Individual
DR. CLARK EDWARD DESHON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D., F.A.A.O
Contact information
Practice address
303 E MAIN ST, OLNEY, IL 62450
(618) 395-2676
(618) 395-2720
Mailing address
303 E MAIN ST, OLNEY, IL 62450-2117
(618) 395-2676
(618) 395-2720
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046008793
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
046008793
—
IL
01
—
09327152
BLUE CROSS BLUE SHIELD
IL
01
—
5290131
AETNA
IL
Enumeration date
10/26/2005
Last updated
08/31/2018
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