Healthcare Provider Details

I. General information

NPI: 1962075986
Provider Name (Legal Business Name): PAIN AND ADDICTION MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 EUCLID AVE STE 207
SAN DIEGO CA
92114-3612
US

IV. Provider business mailing address

4570 ONONDAGA AVE
SAN DIEGO CA
92117-3824
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: AIDAN MATHEW CLARKE
Title or Position: CEO
Credential: MD
Phone: 619-210-9291