Provider Demographics
NPI:1558663690
Name:STEVE CLARK DPM INC
Entity type:Organization
Organization Name:STEVE CLARK DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JON
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:805-459-9666
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E43360Medicaid
480032799Medicare PIN
EX085AMedicare PIN
U80967Medicare UPIN
CAWE4336AMedicare PIN