Provider Demographics
NPI:1245412303
Name:CLARK, DOLPHE SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:DOLPHE
Middle Name:SCOTT
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:D.
Other - Middle Name:SCOTT
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:152 PIONEER LN
Mailing Address - Street 2:STE G
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2563
Mailing Address - Country:US
Mailing Address - Phone:760-872-2244
Mailing Address - Fax:760-872-2245
Practice Address - Street 1:152 PIONEER LN
Practice Address - Street 2:STE G
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2563
Practice Address - Country:US
Practice Address - Phone:760-872-2244
Practice Address - Fax:760-872-2245
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC27196208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C271960Medicaid
CAA88862Medicare UPIN
CA00C271960Medicaid