Healthcare Provider Details

I. General information

NPI: 1821738923
Provider Name (Legal Business Name): GRACE VICTORIA CLARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

993 AVENIDA PICO STE 120
SAN CLEMENTE CA
92673
US

IV. Provider business mailing address

2995 RED HILL AVE STE 200
COSTA MESA CA
92626
US

V. Phone/Fax

Practice location:
  • Phone: 949-829-5533
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA209801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: