Provider Demographics
NPI:1093773681
Name:CLARK, JOEL ROBERTSON (DPM)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:ROBERTSON
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 HAYES ST
Mailing Address - Street 2:SUITE 4A
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117
Mailing Address - Country:US
Mailing Address - Phone:415-759-2014
Mailing Address - Fax:415-759-2015
Practice Address - Street 1:2250 HAYES ST
Practice Address - Street 2:SUITE 4A
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117
Practice Address - Country:US
Practice Address - Phone:415-759-2014
Practice Address - Fax:415-759-2015
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1446213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAN462ZMedicare PIN