Healthcare Provider Details

I. General information

NPI: 1790295228
Provider Name (Legal Business Name): CLARKE PODIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 S MAIN ST
MILTON FREEWATER OR
97862-1342
US

IV. Provider business mailing address

PO BOX 687
MILTON FREEWATER OR
97862-0687
US

V. Phone/Fax

Practice location:
  • Phone: 541-786-2321
  • Fax: 541-854-4020
Mailing address:
  • Phone: 541-786-2321
  • Fax: 541-854-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP00283
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberDP00283
License Number StateOR

VIII. Authorized Official

Name: DR. STACEY J. CLARKE
Title or Position: OWNER
Credential: DPM
Phone: 541-786-2321