Provider Demographics
NPI:1790295228
Name:CLARKE PODIATRY, LLC
Entity Type:Organization
Organization Name:CLARKE PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
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:541-786-2321
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:MILTON FREEWATER
Mailing Address - State:OR
Mailing Address - Zip Code:97862-0687
Mailing Address - Country:US
Mailing Address - Phone:541-786-2321
Mailing Address - Fax:541-854-4020
Practice Address - Street 1:113 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862-1342
Practice Address - Country:US
Practice Address - Phone:541-786-2321
Practice Address - Fax:541-854-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00283213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR6805300OtherBLUE CROSS BLUE SHIELD
OR150541Medicaid
ORBC4203408OtherDEA