Healthcare Provider Details

I. General information

NPI: 1942798145
Provider Name (Legal Business Name): MICHAEL CLENSHAW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11211 VISTA DEL LAGO
SANTA ANA CA
92705-5903
US

IV. Provider business mailing address

11234 ANDERSON ST
LOMA LINDA CA
92350-1716
US

V. Phone/Fax

Practice location:
  • Phone: 714-552-0420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA197884
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: