Provider Demographics
NPI:1497784110
Name:PADDOCK, CLARK STUART (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:STUART
Last Name:PADDOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 N HELIOTROPE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-2538
Mailing Address - Country:US
Mailing Address - Phone:714-624-0772
Mailing Address - Fax:
Practice Address - Street 1:23962 ALICIA PKWY
Practice Address - Street 2:SUITE I1
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-3940
Practice Address - Country:US
Practice Address - Phone:949-452-7699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51251207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A512510Medicaid
CAWA51251DMedicare PIN
CAF79437Medicare UPIN