Healthcare Provider Details

I. General information

NPI: 1215941158
Provider Name (Legal Business Name): AIDAN M CLARKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/28/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W MONTECITO WAY
SAN DIEGO CA
92103-1227
US

IV. Provider business mailing address

1725 W MONTECITO WAY
SAN DIEGO CA
92103-1227
US

V. Phone/Fax

Practice location:
  • Phone: 619-210-9291
  • Fax:
Mailing address:
  • Phone: 619-564-7463
  • Fax: 619-564-7463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG64292
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberG64292
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberG64292
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: