Healthcare Provider Details

I. General information

NPI: 1437157260
Provider Name (Legal Business Name): STACEY J CLARKE D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82013 DOCTOR CARREON BLVD STE H
INDIO CA
92201-5832
US

IV. Provider business mailing address

82013 DOCTOR CARREON BLVD STE H
INDIO CA
92201-5832
US

V. Phone/Fax

Practice location:
  • Phone: 760-610-8398
  • Fax: 442-300-2925
Mailing address:
  • Phone: 760-610-8398
  • Fax: 442-300-2925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE5243
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP00283
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5243
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: