Healthcare Provider Details

I. General information

NPI: 1861519415
Provider Name (Legal Business Name): STEVE RUSSELL CLARKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 SANTA MARIA WAY SUITE A
SANTA MARIA CA
93455-2118
US

IV. Provider business mailing address

2050 S BLOSSER RD
SANTA MARIA CA
93458-7310
US

V. Phone/Fax

Practice location:
  • Phone: 805-934-5400
  • Fax: 805-938-9207
Mailing address:
  • Phone: 805-361-8028
  • Fax: 805-361-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG 62802
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: