Provider Demographics
NPI:1114952462
Name:CLARK, STEVEN JON (DPM)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:JON
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 1:911 OAK PARK BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3406
Mailing Address - Country:US
Mailing Address - Phone:805-481-9100
Mailing Address - Fax:805-481-9199
Practice Address - Street 1:911 OAK PARK BLVD
Practice Address - Street 2:STE 106
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3406
Practice Address - Country:US
Practice Address - Phone:805-481-9100
Practice Address - Fax:805-481-9199
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4336213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E43360Medicaid
CA000E43360Medicaid
CAWE4336AMedicare PIN
U80967Medicare UPIN
EX088ZMedicare PIN