Provider Demographics
NPI:1629089404
Name:CLARK, CHESTER DEAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:DEAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 S EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-2406
Mailing Address - Country:US
Mailing Address - Phone:714-535-2806
Mailing Address - Fax:714-999-1167
Practice Address - Street 1:1611 S EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-2406
Practice Address - Country:US
Practice Address - Phone:714-535-2806
Practice Address - Fax:714-999-1167
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2010-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2464213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE2464Medicare ID - Type Unspecified
CAT11342Medicare UPIN