Provider Demographics
NPI:1558490763
Name:STACEY J. CLARKE DPM, PC
Entity Type:Organization
Organization Name:STACEY J. CLARKE DPM, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
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:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00283213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150541Medicaid
ORU30842Medicare UPIN
ORR0000SGBNJMedicare ID - Type Unspecified