Healthcare Provider Details

I. General information

NPI: 1114952462
Provider Name (Legal Business Name): STEVEN JON CLARK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 06/15/2024
Certification Date: 06/15/2024
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 Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4336
License Number StateCA

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:
Title or Position:
Credential:
Phone: