Provider Demographics
NPI:1477680569
Name:STACEY J. CLARKE D.P.M., P.C.
Entity Type:Organization
Organization Name:STACEY J. CLARKE D.P.M., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:541-963-0265
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00283332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU30842Medicare UPIN
ORR0000SGBNJMedicare Oscar/Certification
OR4222100001Medicare NSC