Provider Demographics
NPI:1891300810
Name:MA, CLARK DAN
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:DAN
Last Name:MA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7395 RAINBOW DR APT 3
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-5346
Mailing Address - Country:US
Mailing Address - Phone:408-300-4265
Mailing Address - Fax:
Practice Address - Street 1:3801 MIRANDA AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1207
Practice Address - Country:US
Practice Address - Phone:650-493-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist