Provider Demographics
NPI:1114952462
Name:CLARK, STEVEN JON (DPM)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:JON
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 W TEFFT ST STE A
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9288
Mailing Address - Country:US
Mailing Address - Phone:805-619-5610
Mailing Address - Fax:805-619-5179
Practice Address - Street 1:699 W TEFFT ST STE A
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9288
Practice Address - Country:US
Practice Address - Phone:805-619-5610
Practice Address - Fax:805-619-5179
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4336213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E43360Medicaid
CA000E43360Medicaid
CAWE4336AMedicare PIN
U80967Medicare UPIN
EX088ZMedicare PIN