MEDICARE: ABIGAIL CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	A165554	CA

General Provider Information

NPI Number	:	1033616032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIGAIL CLARK

Provider Business Mailing Address
First Line	:	1880 CAMINO DE LA REINA # 1147
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1539
Country	:	US
Telephone Number	:	619-688-8111
Fax Number	:

Provider Business Practice Location Address
First Line	:	1880 CAMINO DE LA REINA # 1147
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1539
Country	:	US
Telephone Number	:	619-688-8111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2018
Last Update Date	:	03/16/2026

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