Healthcare Provider Details

I. General information

NPI: 1558663690
Provider Name (Legal Business Name): STEVE CLARK DPM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 W TEFFT ST STE A
NIPOMO CA
93444-9288
US

IV. Provider business mailing address

699 W TEFFT ST STE A
NIPOMO CA
93444-9288
US

V. Phone/Fax

Practice location:
  • Phone: 805-619-5610
  • Fax: 805-619-5179
Mailing address:
  • Phone: 805-619-5610
  • Fax: 805-619-5179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000E43360
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name: STEVEN JON CLARK
Title or Position: OWNER
Credential: DPM
Phone: 805-459-9666