Provider Demographics
NPI:1528104650
Name:CLARK, THERESA ROSS (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:ROSS
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:L
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5343 HUARACHA CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-1904
Mailing Address - Country:US
Mailing Address - Phone:619-709-5009
Mailing Address - Fax:
Practice Address - Street 1:2067 W VISTA WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6031
Practice Address - Country:US
Practice Address - Phone:760-726-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE24637207R00000X
CAA110524207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program