MEDICARE: STACEY J CLARKE D.P.M.

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	213ES0103X	Foot & Ankle Surgery Podiatrist	DP00283	OR
2	213ES0103X	Foot & Ankle Surgery Podiatrist	E5243	CA
3	213E00000X	Podiatrist	E5243	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437157260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY J CLARKE D.P.M.

Provider Business Mailing Address
First Line	:	82013 DOCTOR CARREON BLVD STE H
Second Line	:
City	:	INDIO
State	:	CA
Zip	:	92201-5832
Country	:	US
Telephone Number	:	760-610-8398
Fax Number	:	442-300-2925

Provider Business Practice Location Address
First Line	:	82013 DOCTOR CARREON BLVD STE H
Second Line	:
City	:	INDIO
State	:	CA
Zip	:	92201-5832
Country	:	US
Telephone Number	:	760-610-8398
Fax Number	:	442-300-2925

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

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	04/16/2025

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