Provider Demographics
NPI:1124184593
Name:STARK, CLINTON RUSSELL (DC)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:RUSSELL
Last Name:STARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13771 NEWPORT AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-4693
Mailing Address - Country:US
Mailing Address - Phone:714-368-7600
Mailing Address - Fax:714-368-7630
Practice Address - Street 1:13771 NEWPORT AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-4693
Practice Address - Country:US
Practice Address - Phone:714-368-7600
Practice Address - Fax:714-368-7630
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24623111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA54220DC0246230OtherBLUE SHIELD OF CALIFORNIA