Provider Demographics
NPI:1710391875
Name:CLARK, DONALD CALLAN (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:CALLAN
Last Name:CLARK
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 1:7585 EL PASO ST
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-4302
Mailing Address - Country:US
Mailing Address - Phone:619-508-1060
Mailing Address - Fax:
Practice Address - Street 1:7585 EL PASO ST
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-4302
Practice Address - Country:US
Practice Address - Phone:619-508-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41987207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology