Healthcare Provider Details

I. General information

NPI: 1174126965
Provider Name (Legal Business Name): JUDSON CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 HOSPITAL DR BLDG 3
MOUNTAIN VIEW CA
94040-4106
US

IV. Provider business mailing address

14245 W PARK AVE
BOULDER CREEK CA
95006-9304
US

V. Phone/Fax

Practice location:
  • Phone: 650-863-9000
  • Fax:
Mailing address:
  • Phone: 408-571-8439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number769882
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: