Provider Demographics
NPI:1437157260
Name:CLARKE, STACEY J (DPM)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:CLARKE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 N HALL ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3807
Mailing Address - Country:US
Mailing Address - Phone:541-963-0265
Mailing Address - Fax:541-963-6176
Practice Address - Street 1:1408 N HALL ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3807
Practice Address - Country:US
Practice Address - Phone:541-963-0265
Practice Address - Fax:541-963-6176
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00283213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150541Medicaid
ORU30842Medicare UPIN
OR4222100001Medicare NSC
OR150541Medicaid