Healthcare Provider Details

I. General information

NPI: 1053722124
Provider Name (Legal Business Name): JOHN H CLANCY DO AND TARA LEIGH CLANCY DO MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 S MELROSE DR
VISTA CA
92081-8788
US

IV. Provider business mailing address

2375 S MELROSE DR
VISTA CA
92081-8788
US

V. Phone/Fax

Practice location:
  • Phone: 760-305-1900
  • Fax: 760-305-1910
Mailing address:
  • Phone: 760-305-1900
  • Fax: 760-305-1910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9695
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9614
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN HAROLD CLANCY
Title or Position: PRESIDENT
Credential: D.O.
Phone: 760-305-1900