Provider Demographics
NPI:1376728048
Name:CLARK, STACY J (DO)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24920 GREENSBRIER DR
Mailing Address - Street 2:
Mailing Address - City:STEVENSON RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91381-1830
Mailing Address - Country:US
Mailing Address - Phone:661-286-9996
Mailing Address - Fax:
Practice Address - Street 1:27107 TOURNEY RD
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91355-1860
Practice Address - Country:US
Practice Address - Phone:661-222-2154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine