Provider Demographics
NPI:1508175092
Name:STUPPARD, CLARENCE A SR (ADMINISTRATOR)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:A
Last Name:STUPPARD
Suffix:SR
Gender:M
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 BRIGHTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-1922
Mailing Address - Country:US
Mailing Address - Phone:215-624-1321
Mailing Address - Fax:215-624-1034
Practice Address - Street 1:2924 BRIGHTON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1922
Practice Address - Country:US
Practice Address - Phone:215-624-1321
Practice Address - Fax:215-624-1034
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA16713601172V00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No172V00000XOther Service ProvidersCommunity Health Worker