Provider Demographics
NPI:1962506238
Name:CLANCY, JOHN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CLANCY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 S MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-8788
Mailing Address - Country:US
Mailing Address - Phone:760-305-1900
Mailing Address - Fax:760-305-1910
Practice Address - Street 1:2375 S MELROSE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-8788
Practice Address - Country:US
Practice Address - Phone:760-305-1900
Practice Address - Fax:760-305-1910
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093708207R00000X
CA20A9614207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
L74217Medicare ID - Type Unspecified
G55419Medicare UPIN
IL036093708Medicaid